N3561 Physical Assessment

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N3561 Physical Assessment Student_____________________________________________________ ____ Date___________________ Patient initials_______________________________Medical diagnosis_________________________________ BP__________HR_______R__________T________O2Sat_______w/O2? Y/NReported?Y/N Time______To whom? __________ | BP_________ HR________R_________ T_________O2 Sat_______ w/O2? Y / NReported?Y/N Time____To whom? __________ | NeuromuscularMotor functionGait / balance | Neurological/PsychologicalLOCAffect /MoodSpeech PupilsLanguage spokenVisual acuityHearing | | | | | Skin/ Oral mucosaColor/edemaBony prominencesIncisions, dressings& drainageSurgical drains | CardiovascularHeart/apical Peripheral circulation…show more content…
(e.g., Lisinopril 20 one tab po every day/ACE inhibitor) | How are the medications related to the patient’s condition & pathophysiology of the disease? | What is the usual dosage?Is the patient's dose within normal limits? | What are two or three major nursing implications of this drug? (i.e. need to monitor K+ levels) | | | | | | | | | | | | | | | | | | | | | | | | | List patient's meds, classification & dosage. (e.g., Lisinopril 20 one tab po every day/ACE inhibitor) | How are the medications related to the patient’s condition & pathophysiology of the disease? | What is the usual dosage?Is the patient's dose within normal limits? | What are two or three major nursing implications of this drug? (i.e. need to monitor K+ levels) | | | | | | | | | | | | | | | | | | | | | | | | | What lab values are pertinent considering the pathophysiology? List the lab value, the normal range, and describe how the value is related to the pathophysiology. Tests | Normal Values | Date/ values | Date/ values | Why done & significance of values in view of patient's condition.…show more content…
This includes lab and x-ray results, and other pertinent tests, procedures, etc. Clinical day is for providing care to your selected patient(s), observing the role of the nurse, assisting your assigned nurse, and proactively seeking skills and procedures, and other learning opportunities. It is not to be used for completing care map. Objective: organize and synthesize collected subjective and objective data, and incorporate the pathophysiology to create a focused care map that is relevant to your patient(s). * First, read about the pathophysiology of your patient(s) medical diagnosis(es). You may want to start drawing your concept map at this time. * Review head to toe physical assessment, and transfer to care map the relevant physical findings that correlate with your patient’s (s’) medical diagnosis(es) * Review remaining objective data (labs, meds, etc.) and transfer relevant items to diagnostics

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