HEAD-TO-TOE ASSESSMENT
Name Age Ward: Diagnosis:
BP: ™ HR R oz, we Height
—LEVEL OF CONSCIOUSNESS— ORIENTATION- PAN-
OAwake ODrowsy OPerson O Time OYes ONo
OAlert [ Sedated OPlace O Situation DAcute O Chronic
DORestless O Confused o o
S T - = 12345678910
OClean DEvenydisttbuted [OCalm
Gooperative OO Uncooperative,
Withdrawn | Locaton_______
ODirty OUnevenly distribwted [ Pleasant [ Restless ~ Aggravating Factor
a MMNM._-«& O Thick/full O Angry/ O Anxious —_—
piioomed sparse/Hair Loss — Agitated R R
o ‘COMMUNICATION-
Duration/Frequency:
Conjunctiva:-EVES OVerbal [ Mouth Words
OPink OMoist Olntact 0 Write Notes [ questions
Nods yes/no —_ ABDOMEN———
L
OWhite Olntact (JOther: Senmmmmes pemsegeicitiE | "
Abnormal Discharge:
OYes
Ui
0 Other.
Muscl movermens D Symmetrical
o
CRounded
s Bowel Sounds:
——HEART & CHEST—— [ Abcent [JHypoactive
Pupils:
sy
Inspectior
Nomo Elfres
Dmncfi
[OHyperactive
DOEqual [JReactive to light
ORound [ Accomodating O Symmetrical [ Round/Convex -
Abnormal Findings: Oother [ Grip stren
OPinpoint [JUnequal: P>L or L-R APical Heart Rate:__beats/min
OFixed Rhythm: Range of Rem
5[Capillary
- OReguiar Dllrequiar e
OMdine OStninac Heart Sounds:
O Symmetrical [ Lesion: O Normal/Distinct [] Distant ———LOWER EXT.
0 Congestion O Muttied OlExra sounds [ Pecal pusk:
O Sneezing Other: O Murmur DGallop Disieng QWeak 0ratie
————ars — Breath Sounds: sapilary e Refil
tion
O Symmetrical [ SkinIntact 0 Clear ODecreased[ Dorsale Pedis Puise
0 Earwax/Discharge OCrackes DOiAbsent CJPosteror Tiblal Pulse
—
Olesox____ OWheezing FfOf i
ClErat e Respiratory Rhythm: —
—— W0UT—— DO Regular Dlregular Temperatre (1ot
Warm Lcosl CI o!
OPink OMoist ODry OSores Depth: Zufi.En_um_ o_ya.wmn 3
Do == Hiiba Olrregular Obiaphoretic ODry
———§0——— OAccessory. OShallow Turgor [ Elastic
P ‘muscle use Ofened OlEdena
O Lumps/bumps. — 0 Cok or.
0O Other. 0 Symmetrical O Curvature O Pressure Ulcer
AT AR O Abnormalities [] Wound
0 Other
, NUR 114
Maternal & Child Nursing
Clinical Packet
, NUR 114
Maternal Child Nursing
Clinical Assignment Overview
Post Partum/Newbor
Postpartum/Newborn Quis: To be fumed in af 0900 on 1/18/2024.
Postpartum/Newborn Workheet: 1o guide you in nformation collection neededyourfor clnicalCinrep.
Pastpartum/Newbor CinPrep: To be subrmified by 12 noon the Safurday affer permanent record. day.
Al documentation must be approved BEFORE documenfing on fhe pafient's
In ClinPrep you must document:
Learming Objecives, Pafient Hitory. Diagnosis, Labs, Meds, Diagnasfcs, Pricrity Care Pion [atleast 5
intervenians- ONLY 1 feaching and ONLY | assessment). 180, Vita Signs (o), Orders
In Charting section: Foil ik, Misc Note for your narnaiive nofes, OB Postpartum assessment, Newborn
ssessment. newbiom APGAR, Balard Score, Nursing core, freafments, smoking cessation, and diug screen f
appicable,
You must lso complefe allsections of the post clinical section except for the sits
Labor & Deilvery:
Labor and Delivery Quis: To be furned in af 0900 on 1/16/2024.
Labor and Delvery Workshee: 1o guide you ininformation collection needed for ClinPrep.
Labor and Delvery ClisPrep: 1o be submifled by 12 noon the Saturday affer you clical day.
In ClinPrep you must document:
Leaming Objecfives, Pafient Hisory. Diagnosis. Labs. Meds, Diagnostics.Priority Care Plan (atleast S
inferventions. ONLY 1 teaching ond ONLY 1 assessment). 4.0, VitalSigns fall, Orders.
In Charing section: il sk Misc Nofe for your narralive notes, OB Anfepartum assessment, “Newbor
assessment,“newbom APGAR. *8allord Score, Nursing care, freaiments, smoking cessafion and drug screenf
appicable.
“Newbom nfo needed oniy if pafient devers on your shif.
You must also complefe all sections of the postelinical secon except for he sels
QUIZZES: You are reauired fo compee @ quiz before coming o cincal. Please subrmitin @ manila envelope.
with your name. and NU1 14 or NUR 209 marked clearl i fhe upper Ieff comer of e envelope. Quizes are fo
be handwiitien, legible. and in black ink.
Clinical Evaluation: A assignments are fo be furnedinin ClinPrep by 12 noon the Safurday after your
inical sif. Assignments afe 1is point are considered lafe and a core of 1" will be given for cinical
paperwork. Please remember fhal students are accountable for cliical competencies. The studen wil be.
evaluated on fhe following e (3] cilfical roles
1. Provider of Core
2 Manager of Care.
3. Member of Discipline
The performance benaviors on each clnical evaluaion in CinPrep refiect learning abjecives and are used o
dently competencies and deficiencies. Cinical insfuctors and sfudents wil base fher evaluation on fhe.
foMowing generai description of behaviors
i ciical performance evaluation criteria: (hree) or more 1s in any one objective (or ow) consfitles.
afallure of NUR 114,
“In ciical witien work grading citeia: 4 (fou) of more 1's or 2's in any ane objective (of ow) consfitutes o
failure of NUR 114
Name Age Ward: Diagnosis:
BP: ™ HR R oz, we Height
—LEVEL OF CONSCIOUSNESS— ORIENTATION- PAN-
OAwake ODrowsy OPerson O Time OYes ONo
OAlert [ Sedated OPlace O Situation DAcute O Chronic
DORestless O Confused o o
S T - = 12345678910
OClean DEvenydisttbuted [OCalm
Gooperative OO Uncooperative,
Withdrawn | Locaton_______
ODirty OUnevenly distribwted [ Pleasant [ Restless ~ Aggravating Factor
a MMNM._-«& O Thick/full O Angry/ O Anxious —_—
piioomed sparse/Hair Loss — Agitated R R
o ‘COMMUNICATION-
Duration/Frequency:
Conjunctiva:-EVES OVerbal [ Mouth Words
OPink OMoist Olntact 0 Write Notes [ questions
Nods yes/no —_ ABDOMEN———
L
OWhite Olntact (JOther: Senmmmmes pemsegeicitiE | "
Abnormal Discharge:
OYes
Ui
0 Other.
Muscl movermens D Symmetrical
o
CRounded
s Bowel Sounds:
——HEART & CHEST—— [ Abcent [JHypoactive
Pupils:
sy
Inspectior
Nomo Elfres
Dmncfi
[OHyperactive
DOEqual [JReactive to light
ORound [ Accomodating O Symmetrical [ Round/Convex -
Abnormal Findings: Oother [ Grip stren
OPinpoint [JUnequal: P>L or L-R APical Heart Rate:__beats/min
OFixed Rhythm: Range of Rem
5[Capillary
- OReguiar Dllrequiar e
OMdine OStninac Heart Sounds:
O Symmetrical [ Lesion: O Normal/Distinct [] Distant ———LOWER EXT.
0 Congestion O Muttied OlExra sounds [ Pecal pusk:
O Sneezing Other: O Murmur DGallop Disieng QWeak 0ratie
————ars — Breath Sounds: sapilary e Refil
tion
O Symmetrical [ SkinIntact 0 Clear ODecreased[ Dorsale Pedis Puise
0 Earwax/Discharge OCrackes DOiAbsent CJPosteror Tiblal Pulse
—
Olesox____ OWheezing FfOf i
ClErat e Respiratory Rhythm: —
—— W0UT—— DO Regular Dlregular Temperatre (1ot
Warm Lcosl CI o!
OPink OMoist ODry OSores Depth: Zufi.En_um_ o_ya.wmn 3
Do == Hiiba Olrregular Obiaphoretic ODry
———§0——— OAccessory. OShallow Turgor [ Elastic
P ‘muscle use Ofened OlEdena
O Lumps/bumps. — 0 Cok or.
0O Other. 0 Symmetrical O Curvature O Pressure Ulcer
AT AR O Abnormalities [] Wound
0 Other
, NUR 114
Maternal & Child Nursing
Clinical Packet
, NUR 114
Maternal Child Nursing
Clinical Assignment Overview
Post Partum/Newbor
Postpartum/Newborn Quis: To be fumed in af 0900 on 1/18/2024.
Postpartum/Newborn Workheet: 1o guide you in nformation collection neededyourfor clnicalCinrep.
Pastpartum/Newbor CinPrep: To be subrmified by 12 noon the Safurday affer permanent record. day.
Al documentation must be approved BEFORE documenfing on fhe pafient's
In ClinPrep you must document:
Learming Objecives, Pafient Hitory. Diagnosis, Labs, Meds, Diagnasfcs, Pricrity Care Pion [atleast 5
intervenians- ONLY 1 feaching and ONLY | assessment). 180, Vita Signs (o), Orders
In Charting section: Foil ik, Misc Note for your narnaiive nofes, OB Postpartum assessment, Newborn
ssessment. newbiom APGAR, Balard Score, Nursing core, freafments, smoking cessation, and diug screen f
appicable,
You must lso complefe allsections of the post clinical section except for the sits
Labor & Deilvery:
Labor and Delivery Quis: To be furned in af 0900 on 1/16/2024.
Labor and Delvery Workshee: 1o guide you ininformation collection needed for ClinPrep.
Labor and Delvery ClisPrep: 1o be submifled by 12 noon the Saturday affer you clical day.
In ClinPrep you must document:
Leaming Objecfives, Pafient Hisory. Diagnosis. Labs. Meds, Diagnostics.Priority Care Plan (atleast S
inferventions. ONLY 1 teaching ond ONLY 1 assessment). 4.0, VitalSigns fall, Orders.
In Charing section: il sk Misc Nofe for your narralive notes, OB Anfepartum assessment, “Newbor
assessment,“newbom APGAR. *8allord Score, Nursing care, freaiments, smoking cessafion and drug screenf
appicable.
“Newbom nfo needed oniy if pafient devers on your shif.
You must also complefe all sections of the postelinical secon except for he sels
QUIZZES: You are reauired fo compee @ quiz before coming o cincal. Please subrmitin @ manila envelope.
with your name. and NU1 14 or NUR 209 marked clearl i fhe upper Ieff comer of e envelope. Quizes are fo
be handwiitien, legible. and in black ink.
Clinical Evaluation: A assignments are fo be furnedinin ClinPrep by 12 noon the Safurday after your
inical sif. Assignments afe 1is point are considered lafe and a core of 1" will be given for cinical
paperwork. Please remember fhal students are accountable for cliical competencies. The studen wil be.
evaluated on fhe following e (3] cilfical roles
1. Provider of Core
2 Manager of Care.
3. Member of Discipline
The performance benaviors on each clnical evaluaion in CinPrep refiect learning abjecives and are used o
dently competencies and deficiencies. Cinical insfuctors and sfudents wil base fher evaluation on fhe.
foMowing generai description of behaviors
i ciical performance evaluation criteria: (hree) or more 1s in any one objective (or ow) consfitles.
afallure of NUR 114,
“In ciical witien work grading citeia: 4 (fou) of more 1's or 2's in any ane objective (of ow) consfitutes o
failure of NUR 114
