Physical Assessment Essay

289 Words2 Pages
Complete Physical Assessment. Introduce self and ID patient. Ask for name and date of birth. Confirm name with ID band. Wash Hands. Identify chief complaint using scale of 0 - 10 Type of pain: Intensity, frequency, location, and quality (sharp/dull) Also discuss what helps alleviate the pain. Inform the patient of everything you're going to do BEFORE you do it. A/A/ O x 3 (Awake, Alert and oriented to person, place and time) P.E.R.R.L.A. ( Pupils Round Reactive to Light and Accommodation) Check for Facial symmetry Bilateral hand and leg strength and Range of Motion (on a scale of 0-5) Vital signs: checklist - Normal range: 60-100 BPM __ Temporal __ Brachial __ Popliteal __ Facial __ Radial __ Posterior Tibialis __ Carotid __ Femoral __ Pedal The Apical pulse is a Central pulse: ____Apical (found at the 4th or 5th midclavicular intercostal space) Check respirations while checking pulse. Normal range 14 - 20 Temperature : check with back of hand and thermometer. Blood pressure: Normal range 120/80 Systolic: Diastolic: Capillary refill - 2 seconds or less for total color restoration. Auscultation of respiratory noises: See chart on back. Listen for crackling or rubbing. 2 Lobes on the left side 3 on right. Breathe in through nose and out through mouth. Bowels Auscultation on the four (4) abdominal quadrants. At least 2 points in each quadrant, listen for hyper or hypoactive bowel sounds Palpation and percussion are performed AFTER Auscultation. Skin: Color, texture, wounds, smell, temperature, texture and any other abnormalities. Document where the abnormalities are on the body and their size in centimeters. Turgor test - Skin elasticity Edema- checklist: __ 2mm +1 __6mm +3 __ 4mm +2 __ 8mm 4+ None__ NAME:_____________________________

More about Physical Assessment Essay

Open Document