Professional Documents
Culture Documents
Questions to Patient
Report of Findings
Introduction
Gather equipment, knock on door and wash hands
Hello Mrs. Morrison, my name is Sianna and I will be your student nurse today. How are you doing today? Can I check your ID band? Can you tell me your name and date of birth? Do you have any allergies to any foods, medications or latex? I would like to do a physical assessment and ask you a few questions. Is not a good time? Good, I am going to provide us with some privacy. (pull curtain)
Pull up chair and position self at eye level with patient
How did you sleep last night? Do you have any concerns today? Now I am going to check your vital signs.
Take temp. Put cuff on one arm, pulse ox on the other and run machine while checking radial pulse and respirations.
Patients blood pressure is ___/___ on her right arm in the supine position. Radial pulse is ____, regular rate and rhythm. Oxygen saturation is ___% on room air. Respirations are ____ breaths per minute with regular rate and rhythm, non-labored. Oral temperature is ___F.
Are you having any pain today?
Patient is A&O x3, oriented to person, place and time Patient appears to be well nourished with no apparent distress. Patient has good personal hygiene and no obvious body or breath odors. Affect and behavior are appropriate for the situation. Facial expressions are symmetrical and appropriate. Speech is clear and unimpaired.
Integument
Inspect skin for color, temp, moisture and texture; head, both arms and both legs with back of hands.
Skin color is appropriate to race. No obvious elevations in temperature noted. Skin is dry, warm and smooth. No skin lesions observed No tenting observed.
Actions
Questions to Patient
Report of Findings
Patient is not wearing any corrective hearing devices and responds appropriately to spoken word.
Inspect lips for symmetry, color, moisture or lesions.
Respiratory pattern is regular and symmetrical. Effort appears to be non-labored with no obvious retractions or use of accessory muscles.
Auscultate anterior right and left breath sounds - 2nd intercostal space, mid-clavicular line, left and right Auscultate lateral breath sounds at 5th intercostal space anterior to mid-axillary line - where the breast starts (in line with nipple) Auscultate posterior right and left breath sounds in a butterfly pattern, snake back and forth - 6 locations starting above clavicle
Heart
Are you having any chest pains? Do you feel like your heart is pounding or beating irregularly?
Auscultate apical pulse at apex, 5th intercostal space, can be over breast tissue - nipple - diaphragm and bell
Apical pulse has regular rate and rhythm with no obvious murmurs, gallops or rubs
Check capillary refill on both hands and feet
Actions
Questions to Patient
Report of Findings
Abdomen
Are you having any nausea, vomiting, diarrhea, constipation or problems with urination?
Inspect contour of abdomen
Neuromuscular/Peripheral Vascular
Are you having any numbness or tingling? Are you having any calf pain?
Inspect upper and lower extremities for muscle wasting
Movement and sensation of toes are intact bilaterally. Toes are pink and warm to touch bilaterally.
Assess calves
Actions
Questions to Patient
Report of Findings
There are no IV sites or pumps, no medical equipment, no incisions or wounds present, and no apparent drains or TED hose.
Thank you Mrs. Morrison, your assessment is complete. Do you have any questions?
Focused Cardiovascular
Can you tell me your name again please? Do you know where you are right now? Do you know what day of the week it is?
Heart rate and rhythm are regular with no murmurs, gallops or rubs
Assess pulse deficit by listening to apex at 5th intercostal, mid-clavicular line; nipple area, while checking radial pulse
Thank you Mrs. Morrison, your assessment is complete. Do you have any questions?
Actions
Questions to Patient
Report of Findings
Focused Respiratory
Can you tell me your name again please? Do you know where you are right now? Do you know what day of the week it is?
There is ____ amount of sputum that is ____(thick, watery, frothy) and ___in color
Inspect skin and lips for color
Trachea is midline
Inspect chest for symmetry of movement and configuration
Breath sounds are symmetrical with no obvious signs of wheezes, ronchi, crackles, rubs or stridor
Percuss lung fields for dullness in 10 posterior locations, same as auscultation locations
Heart rate and rhythm are regular with murmurs, gallops or rubs
Inspect fingers for clubbing
No clubbing observed
Actions
Questions to Patient
Report of Findings
Thank you Mrs. Morrison, your assessment is complete. Do you have any questions?
Focused Neuro
Can you tell me your name again please? Do you know where you are right now? Do you know what day of the week it is?
Patient appears to be well nourished with no apparent distress. Patient has good personal hygiene and no obvious body or breath odors. Affect and behavior are appropriate for the situation. Facial expressions are symmetrical and appropriate. Speech is clear and unimpaired
Look straight ahead please.
Check pupils for size and PERRLA with penlight. Shine light in each eye twice, checking for direct reaction and opposite eye reaction. Hold pen away, have patient look at it and bring it towards them to focus on.
Muscle strength is appropriate for situation Hand grasps and foot pushes are 5/5 bilaterally
Do you have any numbness or tingling in your fingers or toes? Close your eyes and tell me when you feel me touch your fingers
Actions
Questions to Patient
Report of Findings
Thank you Mrs. Morrison, your assessment is complete. Do you have any questions?