I am a first semester nursing student, and am struggling to write my ROS on a nursing home pt. She is straight psych (dementia, dep, anx) with no other medical complications. She was pretty uncooperative with just about everything, straight up refused her normal shower, but she was orientated x3. She allowed vital signs to be taken, and even joked about the fact we couldn't find her radial pulse (laughed about it, so I do know she was joking).
Due to her lack of cooperation, I couldn't really examine her bowel sounds and such, and her chart had no information about anything ever being abnormal with any system other than her general dementia, irritation, depression (asymptomatic atm) and anxiety.
How would I fill out the paper work for this...? Any examples (normal or not) would be IMMENSELY appreciated!
May 5, '11
I think you are confusing the Review of Systems which is part of the history and should have been in her chart with the physical exam or assessment part since you mention you were not able to do an abdominal exam. The ROS is a list of conditions you ASK the patient if they have ever had in each system
If you did not do the physical assessment then you will not be able to accurately document your findings. How do you know what her lungs sounded like? Did she have a murmur? Were her pupils reactive to light? Did you check cranial nerves? The only thing you can accurately document is difficulty locating or an absent radial pulse. What about pedal pulses? You can not fake a physical exam that was not done. As to what type of normal or abnormal findings, check your physical exam book. Well since you gave her a shower, you can document her skin condition, turgor etc.
May 6, '11
A review of systems can take a good while especially if there's something wrong with your patient's mind. I can't see why a teacher would have you do an ROS on all your patients. You really only need a SAMPLE history for what you're doing (if that), and it seems like you're doing a PE instead of a history.
Anyway do what all students do: make it up.