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Brief Head to Toe Assessment, Study notes of Nursing

Head-to-Toe practice write-up with someone outside of class

Typology: Study notes

2023/2024

Uploaded on 06/29/2025

breanna-burton
breanna-burton 🇺🇸

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Date Time Nurses’ Notes
3/06/2
4
1930 Mike Donner
Labs:
Neuro A/O x4, makes eye contact, speech clear, hearing intact, calm expression***
Resp. Lungs clear A/P************************************************
B/P 124/76 Lt Arm, P-82, R-16, T-97.6 F, SaO2 98%, Pain 0/10 *********
Skin W/D/P, abrasion on R lower leg, no open wounds*********************
CV Apical 78, HR reg. *********************************************
Abd. BT x4, abd soft non-tender to light palpation, uniform, flat**************
UE Grips equal and strong, Radial Pulse equal and strong, Cap.refill <3secs.***
LE Foot strength equal and strong, Dorsal Ped. Pulse (DP) equal and strong,
Cap. Refill < 3secs, no edema, no calf tenderness (O) ******************
*********************************************Breanna Burton, SN

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Date Time (^) Nurses’ Notes 3/06/ 4 1930 Mike Donner Labs: Neuro A/O x4, makes eye contact, speech clear, hearing intact, calm expression*** Resp. Lungs clear A/P************************************************ B/P 124/76 Lt Arm, P-82, R-16, T-97.6 F, SaO2 98%, Pain 0/10 ********* Skin W/D/P, abrasion on R lower leg, no open wounds********************* CV Apical 78, HR reg. ********************************************* Abd. BT x4, abd soft non-tender to light palpation, uniform, flat************** UE Grips equal and strong, Radial Pulse equal and strong, Cap.refill <3secs.*** LE Foot strength equal and strong, Dorsal Ped. Pulse (DP) equal and strong, Cap. Refill < 3secs, no edema, no calf tenderness (O) ****************** *********************************************Breanna Burton, SN