head to toe assessment

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Head to Toe Assessment INTEGUMENTARY: He has slightly poor skin turgor. His skin in arms and feet are dry, slightly cracked and scaly. They are soft and cool to touch. He has no lesions and free from redness and discharges. No mass is noted. HEENT: Head is symmetrical and free from lesions. Hair is equally distributed. Headache is claimed. She has anicteric sclerae and pink palpebral conjunctiva. Eyebrows are symmetrical to the eyes. Ears are symmetrical, upper and outer pinnacle is aligned to outer and inner canthus. Cartilage is firm. Free from lesions and discharges. Nose is symmetrical with two nostrils and has patent airway. Free from lesions, redness discharges and mass. Mouth is symmetrical to the face. He has dry and cracked lips. His tongue is pinkish in color, able to move from side to side. Taste buds are still functioning. CARDIO-RESPIRATORY: He has a respiratory rate of 26 cycles per minute and shallow breathing. He does not complain difficulty of breathing. His cardiac rate is 102 beats per minute and his blood pressure is 120/90 mmHg. He has no further problem on cardiac and respiratory system. GASTROINTESTINAL: He claimed of left lower abdominal pain. GENITO-URINARY: He has inadequate urine output and negative for dysuria. MUSCULOSKELETAL: He has difficulty in mobilization and slow body movement because of incision on left lower abdomen and he could not flex his lower extremities. NEUROLOGIC: Due to his present illness, He has mood swings and often has irritated emotional response. He is awake and coherent. He is responsive but always lying on back. EXTREMITIES: His upper extremities is well mobilized but his lower extremities is slightly able to move but with assistance due to incision on left lower abdomen. It is free from redness and masses. ABDOMEN:

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Page 1: Head to Toe Assessment

Head to Toe Assessment

INTEGUMENTARY:

He has slightly poor skin turgor. His skin in arms and feet are dry, slightly cracked and scaly. They are soft and cool to touch. He has no lesions and free from redness and discharges. No mass is noted.

HEENT:

Head is symmetrical and free from lesions. Hair is equally distributed. Headache is claimed. She has anicteric sclerae and pink palpebral conjunctiva. Eyebrows are symmetrical to the eyes. Ears are symmetrical, upper and outer pinnacle is aligned to outer and inner canthus. Cartilage is firm. Free from lesions and discharges. Nose is symmetrical with two nostrils and has patent airway. Free from lesions, redness discharges and mass. Mouth is symmetrical to the face. He has dry and cracked lips. His tongue is pinkish in color, able to move from side to side. Taste buds are still functioning.

CARDIO-RESPIRATORY:

He has a respiratory rate of 26 cycles per minute and shallow breathing. He does not complain difficulty of breathing. His cardiac rate is 102 beats per minute and his blood pressure is 120/90 mmHg. He has no further problem on cardiac and respiratory system.

GASTROINTESTINAL:

He claimed of left lower abdominal pain.

GENITO-URINARY:

He has inadequate urine output and negative for dysuria.

MUSCULOSKELETAL:

He has difficulty in mobilization and slow body movement because of incision on left lower abdomen and he could not flex his lower extremities.

NEUROLOGIC:

Due to his present illness, He has mood swings and often has irritated emotional response. He is awake and coherent. He is responsive but always lying on back.

EXTREMITIES:

His upper extremities is well mobilized but his lower extremities is slightly able to move but with assistance due to incision on left lower abdomen. It is free from redness and masses.

ABDOMEN:

She has a flat, non - tender abdomen. He has active bowel sounds upon auscultation.

GENERAL: Generalized body weakness claimed or noted. He complains of pain upon slight activity. There is also observation of facial grimace upon every change of position.