Head to toe! steps walk thru

Página 1

Awipe

Name, DOB, last holiday

allert orint X3

look skin on face

pull down eye lid, conqentia is pink scalara is white

Penlight/ pupil round react to light, lips moist, no crack, no scar in mouth. Are those your real teeth?

No drainage

feel skin

Carotid pulse (different times)

radial and Brachial pulses together pulse 2 and regular

touch skin warm, pink, dry, no edema wrists

nail beds well groomed caprefils both hands less than 3 seconds

palms clean

what finger touch each hand

turger no tenting

can you lift up both hands

lower gown down

chest symetrical

RR for one min, between 12-20

not labored/ regular

listen to lung sound 8-2-10

clavical 2x

go down sides 2x

sit forward

listen to 10 on back (sports bra shape)

lung sounds clear

had you had a cough>?

(if cough) how long, dry/wet/ color/ how much, thickness, odor

lower gown

apical heart rate 1 min 72 reg

cover back up

squeeze hands equal

lay down flat look at abdomen

last time urinated

size/color/ floaters/ closeness/odor

BM, consistany firm/ color/ size/ odor

asultate 4 quadrants

divid 4 quads.

listen 1 min for active bowl sounds

9 regions palpate

ask if uncomfortable or any pain

grab gloves

Palpate bladder

1,2,3,

check femoral pulse same time

2 + and regular

change gloves and wash hands

lower gown, move blanket

lower extrm

touch skin warm and dry

no edema ankles

toe nail beds, cap refills both

which toes

respond to commands

push against/ pull against

raise both legs up symmetrical

dorsalis ped. pulse both same 1 plus and regular

posterir fibula both same time 1 plus and regular

skin no lesions, no open

bottom feet

put on side roll over

check skin

hang back ears elbows spine an but

no break down

roll back

wash hands

are you able to get up

pulse for one min laying down 72 and regular

lower bed

skidless socks

explain stand up and walk

gait belt

raise head of bed/ sit up

how do you feel gait belt

check pulse 74 and regular sitting up

good to stand

are you ok to walk

take 5 steps

gait is steady

sit back down take gait off

Dchow