Head To Toe Assessment Essay

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An Easy Guide to Head to Toe Assessment
© Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com Neurological Assessment Oriented to:  Person  Place  Time Communication/ Speech:  WNL  Non-verbal  Dysarthria  Aphasia:  Expressive  Receptive  Global Pupils:  PERRLA OR Equal:  Yes  No  R larger  L larger Round:  Yes  No  R abnormal shape  L abnormal shape Reactive to Light:  Yes  N Reaction:  Brisk  Sluggish  R no reaction  L no reaction Accommodation:  R  L (hold finger 4” above nose, bring closer to face, do both eyes maintain focus?)
Glasgow Coma Scale (Score range 0 to 15, Coma =< 7) Eye opening to:  Spontaneous = 4  Verbal command = 3  Pain = 2  No response = 1 Verbal response to:  Oriented, converses = 5  Disoriented, converses = 4  Uses inappropriate words = 3  Incomprehensible sounds = 2  No response = 1 Motor response to:  Verbal command = 6  Localized pain = 5  Flexes and withdraws = 4  Flexes abnormally (decorticate) = 3  Extends abnormally (decerebrate) = 2  No response = 1

Location Head/ Neck R hand L hand RUE LUE RLE LLE

Muscle Tone  WNL  Flaccid  Spastic  WNL  WNL  WNL  WNL  WNL  WNL  Flaccid  Flaccid  Flaccid  Flaccid  Flaccid  Flaccid  Spastic  Spastic  Spastic  Spastic  Spastic  Spastic

Muscle Strength

Sensation  WNL  To pain pain  No response to

Tremor  No  Present

Muscle Strength: 5 = WNL 4 = 75% normal

3 = 50% normal

2 = 25% normal

1 = 10% normal

0 = complete paralysis

Respiratory Assessment Pulse ox:  WNL (95-100%)  WNL for this patient at _____ Cough:  None  Non-productive, dry  Productive  Productive sounding, no sputum Sputum:  None Consistency:  Thick  Thin  Foamy Color:  White  Other, __________________ Oxygen:  N/A Room air  ____ liters/ nasal cannula  ____ % per face mask  Mechanical ventilator Respiratory rate:  WNL  Tachypnea/ hyperventilation (too fast)  Bradypneic/ hypoventilation (too slow/ shallow)...

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