Published Oct 21, 2004
Does anyone have some examples of a proper physical assessment that I may look at for an assignment I have coming up.
Basically we have to pick one resident and include what is called a systems approach. We need to keep it simple as it is in a nursing home enviroment.
Please if you can help in anyway feel free to send me a private message (PM).
Thank you in advance.
VickyRN, MSN, DNP, RN
See if these sites will be of help:
what form do I use for nursing assessment
i think head to toe...and remember if doing heart sounds first try to then listen to bowel sounds before lung sounds..that way you dont have to flip the pt over to listen to the lungs and then back over for the bowel sounds...also you can listen to breath sounds as you listen for the heart...or you can feel them....
mrod, LPN, LVN
I am just wondering but didn't your school give you that information?? All of this stuff is in the books and my school goes over it in lab. Does your school do this as well? If you are not sure what to do, I would ask your instructor or refer to a book or websites....
This is a form that we use at our school of nursing with our first-year (freshmen) students. However, every school of nursing is different, with widely-varying requirements. This is just an example of a clinical biographic data form.
Here what yer ol' Papaw does (after 25yrs of ICU):
Let start with neuro:
"Lethargic. Responds to voice. Oriented X 2 to 3. Follows simple commands. Moves all extremities. PERL. Grips equal, Denies needs or complaints." (You've descibed a sleepy but generally competent person who can be responsible for themself if roused).
Let's go on to the life sciences:
"Resp regular and unlabored. Nasal 02 at 3 liters/min. Breath sound slightly coarse but open to all lung fields. No cough. Heart tones audible, regular S1S2. Abdomen soft, benign, hypoactive bowel sds. Palpable peripheral pulses X 4 extremities. (very weak pedal pulses). No pitting edema. Hands and ankles moderate edema. Color fair-pink. Warm and dry."
(You've described someone who's cardio-vascular system works successfullly at the lungs, heart, gut and all 4 extemities--and you can tell that by looking at the skin and listening and palpating arteries.)
Now let's go to essential organ systems:
"Right SubClav TripleLumenCatheter. D51/2NS with 20KCL at 125cc/hr. Two ports heplocked. Abdom incision with staples, closed and well approximated and healing without inflamation or drainage. NG low suction with scant dark green bile drainage. Foley catheter with clear moderately concentrated urine." (You've described the sharp pointed things we have stuck into your patient and left there, with what ever oozing there is and what it looks like. If there're dressings ('Left lower costal margin with dressing, scant sanguinous shadowing present and stable.") you can put them in here to describe--in this case--a former chest tube site.)
Then lets describe what you would see if you stepped back from the bedside:
"Head of Bed at 15 degrees for comfort. Bed down position. Side Rails up X 2. Call light in hand. Monitor Sinus tach @ 100 to 120. Pulse ox 92 to 96 %. (You've assessed the Pt's Cardio and Neuro capacity to ask for your services, and your ability to recognize the need for your professional services--and you're preparedness to give Nursing Care..)
The little things that come up--they only add to the picture: At 0001 to 0200: Fever noted--102.5 axillary. Heart rate up (120 to 130). BP same. No c/o pain. Resps 22--25/min. Saturation still 97%. I draw cultures from central line, from left AC peripheral site. I send Urine UA and C&S from catheter. Notify Dr........., begin Antibiotics. Tylenol supp given. Patient bathed and linens changed, lotion applied. Temp now 101.1 ax. Cont'd to sponge with moist clothes. Observing. (You've noted any 'exeption' to the original asssessment--have acted on it appropriately and charted the events the actions and the results.)
At the end of your day: You might say "Still moderately elevated temp (101.8 ax. Cont'd sponging with H20. Repeat Tylenol supp at 0430. Heart rate still up, 110 to 120. Vitals otherwise stable."
And the blessed words. "Report given to next shift." You go home, feed the cat, have a drink and go to bed.
That's the 'assessment' game as played by yer ol' Papaw John
zambezi, BSN, RN
Hello!! All good examples so far!! The way I usually go about giving a good report/systems approach is:
History: Any pertinant history: CVA 2004, no residual effects. MI 2001- stent to LAD. Hypertension. Peripheral vascular disease. Diabetic- oral coverage.
I then start at the top and go down:
Neuro: Pt awakens to verbal stimulation. Oriented to person. Needs frequent reorientation to place and time/date. PERL. Follows direction appropriately. MAEs within normal limits/to command. Stregnth equal bilaterally. Temp WNL.
Cardiac: Friction rub noted upon auscultation. Rhythm regualr. (tele: NSR without ectopy). DP/DT pulses 1+. Radial pulses 2+. Cap Refill 2-3 sec. Extremeties cool to touch. No edema or cyanosis noted.
Respiratory: Wheezing noted throughout on auscultation. 3L NC for O2 sats 90-93%. Med nebs administered prn. Pursed lip breathing noted at rest. SOB with minimal exertion.
GU: BS present x4. Abd. soft and nontender. PEG tube in place. TF: Glucerna at 90 cc/hr.
GI: Foley catheter in place. QS. Draining clear amber urine.
PICC line noted LUE. Patent. Dressing CDI.
As for forms, I made up my own. Just keep it basic and get a system down. You can do a pretty through assessment in a couple of minutes- it starts the minute you walk into the room- What does the patient look like. Are they working hard to breathe? Are they cool to the touch, lethargic and pasty in color? Or- are they warm to the touch, alert approprite with no obvious difficulties? Start your assessment before you even talk to the patient and learn a systems approach that makes sense to you. It may take you a couple of tries to find out an order that you like. the more you practice, the easier and faster (and more accurate) you will be..
Indy, LPN, LVN
One thing I noticed, is that I do a head to toe but the systems interlock, so when trying to chart it (and it's chart by exception), I don't chart in the order that I performed it.
Example: edema and pedal pulses I usually consider part of my CV assessment, but swollen feet are the last thing I look at.
And, edema could be considered in the fluid category or possibly respiratory, considering what else is going on. Since mine are mostly cardiac first patients, I chart:
-how I found 'em, physically, what are they doing. (sitting in bed awake?)
-telemetry reading, blood pressure, edema, peripheral pulses,
-other cardiac stuff like murmurs, JVD, groin sites for post cardiac cath
-cough, lung sounds, O2 sats if not normal or changed a lot
-what's going in the IV and how is pt tolerating it
-any problems with elimination, if pt has a foley what is in it?
-any other system that may need attention: if they are constipated, what's the bowel sounds like, what does the abdomen feel like, etc.
Hope that helps.
don't forget to check for third spacing, it happens often. expecially in post op pt. check flanks, chest, hand and feet don't always show edema, surprises are not fun.
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