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Clinical Data Collection Tool

This document provides a head-to-toe assessment of a patient, including: 1) Focused assessments of the patient's airway, breathing, circulation, and level of consciousness. 2) Vital signs including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature. 3) Pain assessments. 4) Examinations of the patient's general appearance, respiratory system, cardiovascular system, gastrointestinal system, genitourinary system, extremities, back, activities of daily living, falls risk, and mobility.

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katiegracemcleod
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36 views

Clinical Data Collection Tool

This document provides a head-to-toe assessment of a patient, including: 1) Focused assessments of the patient's airway, breathing, circulation, and level of consciousness. 2) Vital signs including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature. 3) Pain assessments. 4) Examinations of the patient's general appearance, respiratory system, cardiovascular system, gastrointestinal system, genitourinary system, extremities, back, activities of daily living, falls risk, and mobility.

Uploaded by

katiegracemcleod
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CLINICAL ASSIGNMENT: HEAD TO TOE ASSESSMENT FOCUSED ASSESSMENTS

Date: Student: Airway: Notes:


Pt’s Ini als: Room #: Breathing:
Circula on:
Age: Admission
LOC:
date: Code Orienta on X3:
Safety checks:
status:

Safety and isola on precau ons: **VITALS:


Time: BP: HR: (Reg/Irreg) Site:
Resps /min Sats %: 02 Temp:
Diagnosis and/or Surgery:
**PAIN: L: O: T:
A: R: P:
Analgesia: NVS: GCS: /15 best> eye opening verbal motor
Pupils: L_ R Reac on: L_ R
Previous History: General Appearance: Head/Neck: Motor Strength: hands/arms: feet/legs:
Tubes, Drains, Drsgs, IV’s: Eyes” Mouth/ Sensa on(numb/ ng): hands/arms: feet/legs:
tongue/teeth:Facial Arm dri :
symmetry:
Resp: Ausculta on:
Diet: Respiratory/Chest: Regularity:
WOB/SOB: WOB: Anterior = Right side:
Ac vity:
Chest expansion: Anterior = Le s ide:
ng: Ausculta on: SOB: Posterior = Right side:
use prompts to the right Posterior = Le side: __________________
LAB VALUES:

RESULTS: NORMAL: RESULTS: NORMAL: GI/GU: GI/GU Notes:


Abdo/skin: Abd (shape, distension, tenderness):
Hgb: Mg: BS RLQ: Abd movement/pulsa ons:
Bladder/bowel disten on: BS X4 Quads:
RBC: Ca: Tenderness/masses:
Pain:
Toile ng/ Con nence:
WBC: BUN: Urine output:
Urine/color/clarify/amount: Foley:
LBM:
Platelets: Crea nine: Perineum:

PTT: Glucose: Extremi es: CV/PV/Lympha c:


Arms R/L (pain/deformity/edema/pressure areas/bruises): Chest pain: Onset:
INR: Urinalysis:
Apex (1min):
Legs R/L (pain/deformity/edema/pressure areas/bruises):
Na+: Chest(deformi es/scars):
Peripheral pulses (radial/pedal): CWMS: Hands: Feet:
K+: CWMS: Cap re ll: Cap. Re ll: Hands: Feet:
Handgrip: Flexion (dorsi/plantar): Edema: Calf size/pain:
Skin integrity/pressure areas: Pulses: Radial: Brachial: DP: PT:
MEDICATIONS:
Back/coccyx:

ADLs: Musc. Notes:


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Falls risk: Weight bearing: Muscle strength/ROM x4 limbs:
Tests/procedures:
Gait/balance: Assis ve devices: Bony prominences/joints:

Feeding/swallowing: Sleep: Mobility: Skin Integrity (all bony areas):

NOTES AND PLAN INTERRELATED CONCEPT MAP (FROM GIDDENS, 2017)


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Revised Apr 19 HB/LS

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