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Nursing Sit (NUR 3717) Head to Toe Patient Assessment

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John Marsh
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Florida Atlantic University

Nursing Sit (NUR 3717)

Head to Toe Patient Assessment

NEUROLOGICAL
(LOC) Level of
Consciousness
Alert Awake Lethargic Obtunded Stuper Comatose Confused Decerebrate Decorticate
Oriented x 4: Person Place Time Event Response to touch/voice
Eyes Unaided sight Glasses Contact lens Implants Prosthesis Snellen 20/ Blind
Pupils
Equal Round Reactive to light Accommodates Sluggish Brisk Nonreactive to light Consensual
Pupil size before light ______mm Pupil size after light ______mm
Ears Unaided hearing Hard of hearing Deaf Hearing aid Implant Cerumen Drainage
Extremities Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal
Cranial Nerves – intact
I(smell) II(vision) III+IV+VI(eye movement) V(sensation of face/oral) VII (facial movement/taste)
VIII (hear/balance) IX (taste/swallow) X (chew/gag/speech) XI (shrug/turn head) XII(tongue movement)
Pain Character Onset Location Duration Severity Pattern Associated Factors COLDSPA

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Nursing Sit (NUR 3717) Head to Toe Patient Assessment

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