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make a fake patient up and assessment Level of consciousness, general survey, vital signs
Document the patient’s level of consciousness and whether or not the patient is oriented to person, place, and time.
Document the patient’s orientation to situation by identifying the patient’s ability to describe the reason for seeking care or a description of current health situation.
Describe the patient’s general appearance, including general skin color and manifestations of distress.
Describe the patient’s affect, or mood, as well as verbal and nonverbal behavior.
Document temperature, pulse and respiratory rates, blood pressure, and pain level.
Integument
Note any recent changes in the appearance or condition of the patient’s skin.
Describe the texture of the patient’s skin.
Note the temperature (warm or cool) of the skin and whether it is moist or dry.
Describe skin turgor.
Describe the size, shape and appearance of any moles, lesions, bumps, or wounds.
Document the appearance of IV sites.
Head, face, and neck
Note any pain or tenderness when palpating the head, face, and neck.
Describe hair distribution and note any areas of hair loss.
Eyes
Note the position of the eyes and the color and condition of the conjunctivae.
Document PERRLA and EOMs.
Ears, nose, and throat
Note the position and appearance of the ears.
Describe the appearance of the internal ear.
Note the shape, skin color, and alignment of the nose.
Describe any inflammation or deformity of the nose.
Note any lesions, swelling, bleeding, or drainage.
Inspect the mouth and note hydration status.
Note any discoloration of the gums or any lesions.
Respiratory
Document the respiratory rate, rhythm, and effort, or work of breathing. If you measured his oxygen saturation, be sure to document that as well, along with oxygen use at the time of the exam. For example, “SpO₂ 97% on room air,” or “SpO₂ 89% on 6 L/min O₂ by nasal cannula.”
Note the symmetry, configuration, and any deformities of the thorax.
Note any pain or tenderness over the thorax.
Document percussion findings and chest expansion.
Describe breath sounds and abnormal sounds.
Document the amount, color, consistency, and odor of any sputum.
Cardiac
Document cardiac rate and rhythm. If the rhythm is irregular, note whether it is “regularly irregular” (for example, every third beat is delayed), or irregularly irregular (with no identifiable pattern).
Document the size and location of the PMI, if visible, and the presence of any lifts, heaves, or thrills to palpation over the apex and other precordial landmarks.
Describe heart sounds and any extra sounds such as murmurs, split heart sounds, or friction rubs.
Document whether or not the patient has a pulse deficit.
Document the presence or absence of jugular venous distention.
Note capillary refill.
Document any peripheral edema.
Describe peripheral pulses.
Abdomen
Note the color of the skin over the abdomen, and any scars, rashes, lesions, or striae.
Describe the abdominal contour and symmetry and the status of the umbilicus.
Document bowel sounds in all quadrants.
Document the presence of any bruits.
If you percussed the abdomen, document the tone generated.
Document your palpation findings: whether the abdomen is soft, firm, or distended, and any tenderness, rebound or otherwise, and any masses.
Musculoskeletal Physical assessment.docx Download Physical assessment.docxCare Map Q2, Q3, and Q 4.docx Download Care Map Q2, Q3, and Q 4.docx Note ambulation status and any mobility aids.
Describe gait and posture.
Document the configuration and range of motion of the spine.
Document muscle mass and joint symmetry in the upper and lower extremities.
Document muscle strength and joint range of motion.
Note any pain, tenderness, edema, or warmth near joints.
Note the amplitude and symmetry of peripheral pulses.
Note the results of Romberg testing.
Neurological
Note the level of consciousness and orientation to person, place, and time.
Assess and document orientation to situation.
Describe affect, or mood, and memory, if tested.
Document whether or not the cranial nerves are intact.
Document gait, balance, and coordination in the upper and lower extremities.
Document findings of sensory testing: light touch, sharp/dull discrimination, vibration, and monofilament testing.
Document deep tendon reflexluves and the Babinski reflex, if done.
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