Physical assessment question

[ohyeahuh]

Hi everyone!

Our class have been doing physical assessments at our clinical sites. The only problem I have is what wording to put. For example: LOC: A & O; Cap refill: Normal; Bowel sounds: Present. Like if cap refill is delayed, would I just put delayed or how many seconds? And if pt has no dyspnea, would I put none or N/A? Is there are website that any of you can direct me to with proper wording with physical assessments?

Thank you for your help.

[shrimpchips, LPN]

charting A&O x3 is fine. For capillary refill, I was told to chart "brisk" for 3 seconds or write down the seconds if possible. For bowel sounds, I would chart BS x 4 (quads) and state whether they are normal, hyperactive or hypoactive. If the pt has no dyspnea, how is the patient breathing? sob s (without) dyspnea? even & unlabored s use of accessory muscles? Hope this helps a bit!

For my Health Assessment class, we were required to buy Physical Examination & Health Assessment by Carolyn Jarvis. It's an excellent book and easy to read and provides examples for charting.

[Daytonite, BSN, RN]

There used to be a website that had nice examples of what to write when doing assessments but it was removed from the Internet. All I can suggest is that you look at lots of doctor's histories and physicals in patient charts. Look at examples of Review of Systems and physical exam flow sheets that are check off sheets because they have normal terminology on them. Over time you will learn how people describe different findings or different body parts.

[ohyeahuh]

shrimpchips & Daytonite: A little late but, I just wanted to thank you for your responses! :)

[TexasGirl24]

We were just always told not to use "normal", even though I see nurses use it every day. As far as for while you are in school, I would stay away from that word. Our instructors like us to be specific. We use normoactive, hyperactive or hypoactive for bowel sounds. And cap. refill is either 3 sec.

[ohyeahuh]

TexasGirl24: Thanks for your response. I've been using 3 sec for cap refill and normo, hyper, hypoactive for BS. :)

[Ruth1417]

As a clinical instructor, I am glad to see Texasgirl comment about not using "normal". After all, what is normal for one person is not for the next one. We do use "within normal limits for resident" (we are doing beginning clinicals in a long term care facility.

Do not use " 3 seconds", however. these symbols are easily misunderstood or used wrong. Use the words: less than 3 seconds, or more than 3 seconds.

I do have a question: does your facility use the term " brisk/delayed" or "good/poor" for turgor?