Narrative Charting Resource Sheet - Wording and What to Look for in Head to Toe Assessment

Narrative Charting Resource Sheet –Wording & What to look for in Head to Toe Assessment Systems Data Abnormal – findings out of range or expectation select appropriate wording only Expected normal findings. Specify - do not use word normal. Vital Signs Know normal limits. Document values Pain (6th VS) Denies pain. Values out of range, Reported to ___ Neuro/ Behavior Alert, oriented to time, place & person= A & O X 3/4 = Name,DOB,Place/Time Follows commands & answers appropriately. Speech clear Maintains eye contact PERRLA # mm = Pupils, Equal, Round, Reactive to Light and Accommodation Cardinal Movements Gaze= intact Cranial Nerve checks WNL throughout exam General appearance Neat, relaxed, no signs of distress. Physique well developed. Personal Hygiene maintained Anthropic measure expected range Integumentary Skin pink, warm, dry & intact with elastic turgor. No lesions noted Mucus membranes moist, intact & pink. Bony prominences free of redness MusculoSkeletal Hand grasp Strong & equal bilateral. ROM Full all joints. Denies stiffness / pain with movement. No gross muscle weakness. Absence of joint pain, tenderness or swelling. Posture Erect. Gait Steady. CardioVascular Includes vital signs compared to baseline. Regular, full apical pulse, 60-100bpm for adult, with regular S1 S2 rhythm. BP within pts. baseline. 90-120/60-80 Palpable peripheral pulses + 2 bil X 4 limbs. OR Bil peripheral pulses +2 LE & UE. Capillary refill <3 sec X 4 limbs. Pink moist, mucus membranes & conjunctiva. No neck vein distention observed. No edema noted. IV site (location) free of erythema, swelling or tenderness Location, type, duration. Scale 0-10. What makes it better / worse? A&O X 1 or 2 (specify disoriented to which). Drowsy, lethargic, confused, sedated, unconscious. Withdrawn, agitated, irritable, crying, combative Pupils unequal. Note deviations in size, reactivity Deviations in Cranial Nerve checks throughout – note specific deficit Does not make eye contact. Volunteers no information. Lack of /or inappropriate response to questions. Garbled or slurred speech. HOH. (Hard of hearing) Unshaven, Hygiene unkempt. Visible signs of distress (SOB, crying, grimacing, moaning). Note Facial expression. Note deviations in facial symmetry Abnormal positioning (slumped, leaning, hunched over___, knees drawn). Obese, emaciated. Skin color ashen, cyanotic, or jaundiced. Change in skin pigmentation, texture, or tenting. Skin hot or cool or moist. Skin eruptions, rashes, lesions, wounds (location). report wounds –location/appearance or Covered with dressing-not assessed Unusual hair growth or loss. Nails, thick yellow, broken, or brittle. Hand grasp (unequal / weak or absent). Muscle weakness or atrophy (location). Deformity, joint stiffness or pain. Posture (hunched, leaning, kyphosis, scoliosis, lordosis). Paralysis (where). Amputations, dislocations, fractures, casts, traction assistive devices, elevation or immobilization of extremity or body part. SCD /Ace wrap. (Sequential compress device) AE or AK or BK. Above elbow/knee Below knee Changes in apical pulse (irregular, weak, thready, bounding). Jugular vein distention. BP bounding or difficult to auscultate. peripheral pulses - Asymmetry, weak or absent. Edema pitting or non-pitting (location & grade). Pt. c/o dizzy, faint, chest pain, palpitations, leg pain. Capillary refill >3 seconds (location). Color changes (pallor, cyanosis, rubor, flushed, ashen, ecchymosis). Varicose veins (location). IV site (location) reddened, edema, or tender /pain – reported to__. Ortho BP readings if ordered (lying, sitting, standing). Apical/ radial pulse deficit RESP Respiratory rate 12-20 adult even, regular Depth within acceptable parameters. Quiet, unlabored respirations= No muscle retractions / No use of accessory muscles(neck,shoulder, abd ) Lungs sounds clear all lobes. No adventitious lung sounds Absence of spontaneous cough. O2 sat>93% Chest contour/Shape of thorax = Side to side symmetrical Normal chest shape, with no visible deformities, such as a barrel chest, kyphosis, or scoliosis Skin color matches the rest of the body GI Lips dry & smooth. Mucus membranes moist, pink & smooth. Teeth white & shiny. Gums pink, moist & firm. Tongue medium red or pink, moist & smooth. Abdomen concave or convex, soft, nontender to palpation. No distention noted. Bowel sounds active X 4 quads. Denies N/V/D or constipation. (nausea,vomit,diarrhea) Last BM ___ URINARY Continent. Bladder non-palpable. Urine clear, pale, yellow to amber in color, no sediment. Voids without difficult. Denies dysuria Respiratory rate & type = Dyspnea, bradypnea, tachypnea, SOB. Positioning =lean over table, semi/high Fowler’s, splints chest w/ arm/pillow. Work of breathing= Indrawing of intercostal spaces, Nasal flaring, pursed lip breathing, use of accessory muscles (neck) Lung sounds: = rhonchi, crackles, wheezes… (specify lobe). Cough= dry, hacking Cough= productive - specify sputum color, consistency & amount O2 sat <93%. - re-check & report to whom. Chest contour = Abnormal = Ex: Barrel (seen with COPD), Pigeon chest(Pectus carinatum)Funnel (Pectus Excavatum), Scoliosis Sneezing Nasal discharge. O__ liters /min via: NC, simple mask, non- rebreather mask, re-breather mask, Venturi mask. Taught incentive spirometer X 10 Q2H. Volume ____ ml. Lips dry, cracked, tender. Lesions on mouth/oral mucosa. Mouth dry inflamed, ulcerated, pale, white patches, deep tongue furrows. Teeth discolored, broken, missing-dentures, partial plate, edentulous. Gums inflamed, receding, tender, bleeding. oral hygiene Poor. Abdomen - concave, convex, asymmetric, protruberant, firm, distended, tender or painful. Bowel sounds hypoactive or hyperactive in __quadrant (location). N/V/D (nausea, vomiting, diarrhea) constipation. Last BM __, Flatulence. Ostomy-location-type. Specimens if obtained Palpable bladder (above suprapubic) Last void ___ HNV since ___ (has not voided) Incontinence. C/o dysuria, frequency, dribbling. Urine cloudy, foul odor, color (tea colored, orange, concentrated) with sediment. Catheter type (external, indwelling or suprapubic) Catheter connected to - BSD (bedside drainage) or leg bag. Condensed Steps of the Physical Examination (* see detailed exam notes on following page) 1. Patient's comfort- be certain that the patient is in a relaxed position, properly gowned or draped. 2. The optimal environment= the examination surface should be at a height appropriate for the examiner. Light sources and curtains should be optimally arranged. Television sets, radios, and other noisy distractions should be eliminated. 3. General inspection and Vital signs = Evaluate radial pulse for rate and rhythm. Measure brachial blood pressure. Inspect nails, skin, and hair. Note general appearance, body habitus, hair distribution, muscle mass, movement coordination, odors, and breathing pattern. 4. Head a. Eyes: Examine the conjunctiva, sclera, cornea, and iris of each eye. Test pupils for PERRLA irregularity, accommodation, reaction. Evaluate visual fields & acuity (cranial nerve II), extraocular movement (CN III, IV, VI ) and corneal reflex (CN V). b. Ears: Examine the pinnae and periauricular tissues, (if appropriate: auditory acuity, Weber and Rinne maneuvers *cranial nerve VIII) c. If appropriate: Ophthalmo-otoscopy: oscope can be used in darkened room to examine interior of the eye through the pupillary aperture and after attaching the otoscope head observing the auditory canals and tympani. d. Nose: use pen light examine the nares, note the condition of the mucosa, septum and turbinates. (*if appropriate Cranial Nerve 1) e. Mouth: Examine the lip border, the oral mucosa, the tongue. Assess the teeth for decay, repair, condition of bite. View the pharynx. Evaluate the function of *cranial nerves IX, X, and XII. (If appropriate, evaluate *cranial nerves V, VII. Wisp cotton/Rinne Weber) f. Face: Evaluation of symmetry, smile, frown, and jaw movement will provide information about cranial nerves V and VII. 5. Neck =Palpate the neck with emphasis on the salivary glands, lymph nodes, and thyroid. Look for tracheal deviation. Identify the carotid arteries and auscultate for bruits. Note jugular venous distention. Certain parts of evaluation of this area, jugular venous filling, may warrant review with the patient reclining. Test shoulder strength of the sternocleidomastoid and trapezius muscles (cranial nerves XI and XII). 6. Anterior torso = pt sitting: examine nodes (epitrochlear elbow,axillary) , breasts, Define PMI ,examine heart, abdomen, and thorax 7. Posterior torso = Observe/Evaluate vertebral column, for spinal curvature, chest deformity. Auscultate posterior /lateral lung fields. 8. Complete "sitting" portion of exam = Evaluate proximal/ distal motor strength, deep tendon reflexes, distal pulses and sensation. 9. With the patient supine a. Thorax: Examine the breasts; reexamine the heart, turning the patient to the left lateral decubitus position if appropriate. Auscultate the anterior lung structures. b. Abdomen: After inspection, auscultate, listening for bowel sounds and bruits. Next inspect, percuss, and palpate the abdomen, taking special notice of hepatic or splenic enlargements. c. Proximal lower extremities: Examine the inguinal, femoral, and popliteal regions for adenopathy and pulses . Evaluate range of motion of hips, knees, and ankles. 10. If appropriate With the patient standing = Examine external genitalia of the male. In both male and female, evaluate station and gait. 11. If appropriate, Pelvic and rectal examination = Rectal examination and occult blood testing done simultaneously. In female, pelvic exam performed on an examining table with stirrups. In male, the rectal exam is best performed with pt bent forward position. 12. Gait and coordination can be assessed at the beginning of exam as pt moves to exam table and assessed along with cranial nerves. Cranial nerves When testing the cranial nerves be cognizant of asymmetry. summary of the cranial nerves and their respective functioning: I – Smell – ask pt to breath in through their nose while examiner occludes one nostril at a time to check patentcy. With eyes closed, ask pt to smell alcohol, soap or identifiable smell. Done if reported history suggesting head trauma or toxic inhalation II - Visual acuity, visual fields and ocular fundi – use of Snellen chart for acuity. With one eye at a time test peripheral vision. Face the pt 1 ft away, at eye level. have pt cover their right eye with right hand and look examiner in the eyes. Instruct pt to remain looking you in the eyes and say "now" when examiner's fingers enter from out of sight, into their peripheral vision. Repeat with Left eye. II,III – Pupillary reactions = PERRLA = Pupils Equal Round Reactive to Light and Accomodation III,IV,VI - Extra-ocular movements, including opening of the eyes = Cardinal Movements of Gaze. Have pt keep head straight and without moving head,follow your finger with their eyes as you trace the letter H from left side, middle and right side of pt. V - Facial sensation, movements of the jaw, and corneal reflexes. Palpate jaw and have pt clench then open jaw wide. Have pt close eyes and sweep cotton over temple, side of nose and chin bilaterally. VII - Facial movements and gustation. Inspect the face during conversation and rest noting any facial asymmetry including drooping, sagging or smoothing of normal facial creases. Next, ask the pt to raise their eyebrows, smile showing their teeth, frown and puff out both cheeks. Note asymmetry and difficulty performing these maneuvers. VIII - Hearing and balance. Assess hearing- instruct the patient to close their eyes and to say "left" or "right" when a sound is heard in the respective ear. Vigorously rub your fingers together very near to, yet not touching, each ear and wait for the pt to respond. After this test, ask the pt if the sound was the same in both ears, or louder in a specific ear. If there is lateralization or hearing abnormalities perform the Rinne and Weber tests using the 256 Hz tuning fork IX,X - Swallowing, elevation of the palate, gag reflex and gustation. Ask pt to swallow and note any difficulty doing so. Ask pt if they have difficulty swallowing. Next, note the quality and sound of the pt's voice. Is it hoarse or nasal? Ask pt to open their mouth wide, protrude their tongue, and say "AHH". While the pt is performing this task, flash your penlight into the pt's mouth and observe the soft palate, uvula and pharynx. The soft palate should rise symmetrically, the uvula should remain midline and the pharynx should constrict medially like a curtain. At this time, use a tongue depressor and to test the gag reflex. Perform this test by touching the pharynx with the instrument on both the left and then on the right side, observing the normal gag or cough XI - Shrugging the shoulders and turning the head. observe pt from the rear - evaluate for wasting of trapezius muscles. then, ask the pt to shrug their shoulders as strong as they possible can while the examiner resists this motion by pressing down on the pt's shoulders with their hands. Next, ask pt to turn their head to the side as strongly as they possibly can while the examiner once again resists with their hand. Repeat maneuver on the opposite side. pt should normally overcome the resistance applied by examiner. Note asymmetry. XII - Movement and protrusion of tongue. have pt "stick out their tongue" and move it side to side. Normally, tongue will be protruded from the mouth and remain midline. Note deviations from midline, lack of ability to protrude tongue, tongue atrophy and tongue fasciculations Deep tendon reflexes : Using a reflex hammer, deep tendon reflexes are elicited in all 4 extremities. Note the extent or power of the reflex, both visually and by palpation of the tendon or muscle in question. Rate the reflex with the following scale: 5+ Sustained clonus 4+ Very brisk, hyperreflexive, with clonus 3+ Brisker or more reflexive than normally. 2+ Normal 1+ Low normal, diminished 0.5+ A reflex that is only elicited with reinforcement 0 No response Motor system evaluation = body positioning, involuntary movements, muscle tone and muscle strength Systematically examine all of the major muscle groups of the body. For each muscle group: 1. Note the appearance or muscularity of the muscle (wasted, highly developed, normal). 2. Feel the tone of the muscle (flaccid, clonic, normal). 3. Test the strength of the muscle group. 0 No muscle contraction is detected A trace contraction is noted in the muscle by palpating the 1 muscle while the patient attempts to contract it. The patient is able to actively move the muscle when gravity 2 is eliminated. The patient may move the muscle against gravity but not 3 against resistance from the examiner. 4 5 The patient may move the muscle group against some resistance from the examiner. The patient moves the muscle group and overcomes the resistance of the examiner. This is normal muscle strength. Coordination, Rhomberg Test and Gait - test the pt's ability to perform rapidly alternating and point-to-point movements correctly. rapidly alternating movement -Ask pt to place their hands on their thighs then rapidly turn their hands over and lift them off their thighs. tell them to repeat it rapidly for 10 seconds. Normally this is possible without difficulty. Point to point movement - ask pt to extend their index finger touch their nose, then touch examiner's outstretched finger with the same finger. Ask the patient to go back and forth between touching their nose and examiner's finger. Once this is done correctly a few times at a moderate cadence, ask the patient to continue with their eyes closed. Normally this movement remains accurate when the eyes are closed. Repeat and compare to the other hand. Romberg test -have pt stand still with their heels together. Ask pt to remain still and close eyes. If pt loses their balance, test = positive. Gait - have the patient walk across the room under observation. Gross gait abnormalities should be noted. Next ask the patient to walk heel to toe across the room, then on their toes only, and finally on their heels only. Normally, these maneuvers possible without too much difficulty. note the amount of arm swinging. a slight decrease in arm swinging is a highly sensitive indicator of upper extremity weakness.