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Key Elements of Writing the Assessment Form Of Patient

come on in hi mr. Regan how are you.today well today think I am doing my.hand hygiene as I enter the room sir can.you tell me your name and your date of.birth I'm George HW Reagan born 122 57.the youngest cousin of Ronald Reagan.I checked the name badge here that you.have your band and it matches can you.tell me if you have any allergies I have.none okay so first thing I'm going to do.when I enter the room is I'm going to do.an assessment of ABC's airway is a and I.know that his airway is open because.he's talking to me and breathing I'm.looking at his breathing does it look.easy and regular and yes it does and.then see circulation when I checked his.armband I checked his skin it's warm and.dry and his color is appropriate and so.I know in circulation is intact so as.ABCs are intact next I'm going to talk.to him a little bit and I am aware that.he is awake and alert as opposed to.sleepy or difficult to arouse he's.definitely awakened alert and I'm going.to have to assess whether he is oriented.so first I'm just gonna start by talking.with him and so mr. Regan what brought.you to the hospital I was having.problems with a kidney stone paint last.night.oh okay so then you came to the.emergency room is that right that's how.I did it yes okay and are you having any.pain right now.not at the moment not at all to zero yes.okay all right so just based on our.conversation I can tell that he is.oriented but if I wasn't sure I would.ask some specific questions so mr. egan.can you tell me where you are I'm at the.Harper Hospital okay and can.tell me what season it is winter it's.wintertime and can you tell me who the.president is right now it's Donald Trump.Donald Trump that's right and can you.tell me why you are here because of the.kidney stones that are a challenge for.me sometimes okay all right so I can see.that he is oriented to person place time.and situation so he is oriented times.four wonderful so that starts the basic.assessment I continue with a basic.safety assessment of the environment so.I look and see are there any tubes or.lines or wires and first thing I'm aware.of is oxygen he is wearing a nasal.cannula is it on correctly are the.prongs in the nose as they should be and.I look at the tubing and I see is the.tubing connected to the flow meter as it.should be and I look at the flow meter.and is the setting on the flow meter the.same as what I heard in report or saw in.the medical record I also noticed right.away that he has an IV in his arm here.and the same thing I checked that tubing.all the way back to the pump and I would.look at the pump settings and make sure.that the settings here and the fluid.here matches what I heard in report or.saw in the medical record so I look here.it's a 0.9% sodium chloride and then I.check the settings on the pump as well I.also look around the bag and see are.there any other tubes or drains or wires.is there a urine catheter that it's.fairly common do I see any dreams and.then I'm also looking at the room in.general for a safety assessment do I see.anything that's unsafe like stuff on the.floor but it's a table that's out of.reach a call light that's not in the bed.accessible to the patient sharps laying.around pills on the table electrical.cords I look for all those things make.sure.the environment is safe alright so that.starts out our basic safety assessment.and some from there I'm going to proceed.with doing a physical assessment so mr..Reagan I'm gonna do a physical.assessment and I'm gonna start with your.head and work all the way down to your.feet is that okay that's fine all right.I'm gonna start by looking at your face.can you smile for me very nice alright.so when I'm looking at your face I'm.looking is it symmetrical and when you.smiled was your mouth symmetrical are.your eyes symmetrical can you look to.your right and look to your left.I'm just looking to see if his eyes are.moving symmetrically which they.certainly are and then I'm going to look.at your mouth I see that your lips are.pink and I look inside look at your.mucous membranes and can you stick your.tongue out and your tongue is pink and.moist can you show me your teeth and I.see that your teeth are white and.they're intact I don't see anything.abnormal like Decay's or problems with.the bottom so that all looks nice and.healthy and then I'm gonna move on from.the face and the head to the chest so I.need to look at your chest here I'm just.gonna move your gown down a little bit.and when I look at your chest the first.thing that I looking at with your chest.is to look at the rise and fall of your.chest and you breathe any problem.breathing any shortness of breath.alright good that's very helpful so when.I look at the chest I'm looking and I'm.listening and assessing both both the.heart and the lungs so I'm going to.start by listening to the heart I listen.to the apical pulse which I find the.apical pulse at the midclavicular line.this is the clavicle mid clavicular.would be halfway here's your clavicle.from here to here halfway is going to be.right here and the fifth intercostal.space so I find that by finding this.angle.Louie that's intercostal space blonde.and then here's two and three and four.and five and then right around so it's.basically just right below where the.nipple is and I put my stethoscope on.there and I'm listening for the love dub.so I listen very carefully.and I do several things while I'm.listening to the heart.do I hear the love dub is it regular or.irregular you should be able to hear.that even if you're not a very.experienced nurse and then the last.thing is that I counted the rate how.fast is it going and I count for a full.minute all right then I listen to the.lungs again I use my stethoscope and I.ask my client to take some deep breaths.in and out and I'm gonna listen side to.side so I start at the top of the chest.I move down and I listen side to side.and you're gonna listen all the way down.throughout the whole chest.and then all the way over here to the.side.all right.good and your lungs sound clear alright.then I'm going to move on then I'm going.to look at your abdomen and look at your.belly okay okay so for that I'm going to.ask a couple questions when was your.last bowel movement oh this morning at.7:00 a.m. all right and was it soft and.brown yes okay and when was the last.time you emptied your bladder about.11:30 this morning okay and we're there.any problems with that burning though in.the urine was yellow the normal color.yes okay then I look at the abdomen.shape is the abdomen rounded that would.be normal is it flat that would be.normal or is a very protuberant and.distended that would not be normal and.then I listen with my stethoscope in all.four quadrants.I listen until I hear a ball sound and.then I move on to the next spot and then.I listen the bowel sounds sound like.uncle Tico Tico Tico and then I listen.in four places.so if you notice when I was listening if.you were to draw a line down the abdomen.like this with the umbilicus right in.the middle and a line like this this.would be the four quadrants one two.three four and I listened and all four.quadrants.this is the right upper quadrant so.laptop four quadrant the left lower and.the right lower after I've listened I'm.going to press down under your belly a.little bit if you have any pain let me.know please now you have any pain in.your abdomen no no if he was having any.pain I would for sure want to leave that.area for last because if you start.pressing on the abdomen where it hurts.your assessment is going to be done.their patient's not gonna let you do.anything else.so I use the flats of my fingers and I.press down and I make a little bit of a.circle and it should feel soft to not.feel hard or firm it should feel soft.that would be normal and his the abdomen.does feel.okay now I want to take a look at your.arms.so I'm looking oh my gosh.all right so I'm looking at your arms.and I'm looking to see if there is any.problem with your skin like lesions or.cuts or bruises or anything I do not see.anything abnormal many people when.they're in the hospital they have an IV.or a saline lock so I look at that site.is there any drainage is it red or.swollen or anything abnormal with that.and this looks clean and the dressing.looks dry and intent and then I ask do.you have any problem with numbness or.tingling in your upper extremities nope.can you tell me close your eyes for a.second and tell me when you feel me.touch your arm right now okay yes.okay and can you open your eyes and.squeeze my fingers I'm checking your.strength speed you go squeeze harder the.one hurt me.all right good and press on my hands per.third and then pull my hands toward you.full all right.fantastic so I am also checking your.radial pulses I checked them at the same.time they should feel strong and regular.and I as I was doing all this I was.noting that her skin temperature is warm.and the color is appropriate okay so.let's move down to your legs legs and.I'm gonna look after legs.first stop seemed like the upper.extremities I look and see if there's.anything abnormal on your skin like any.lesions or varicosities or bruises I.check the temperature of your skin it.should be warm all the way down to your.toes which it is I check the pedal.pulses relax.I check on both sides to compare they.should feel strong and regular I check.the capillary refill on your toes it.should be brisk.I ask you to press you press and can you.pull up to check the strength alright.your legs are strong and then can you.close your eyes for a moment and tell me.which like I'm touching love right right.laughs okay good any numbness or.tingling in your legs or loss of.sensation in your toes so all right and.we did check capillary refill on your.toes but I realize we didn't check.capillary refill on the fingers so I'm.going to come back and do that so I can.press on the nail or right on the tips.of the fingers and again it should be.less than three seconds or risk for your.capillary refill all right I'll put your.socks back on sometimes it can be cold.in the hospital right yes the patients.are cold and the nurses are sweating the.temperature in here is very comfortable.though all right so this rating one last.thing I'm going to have you sit on the.side of the bed because I'm going to.listen to your lungs in the back okay so.if you could sit facing towards me a.little bit there you go.so on the back I listened in the front.before and now I'm going to come back.and we'll listen in the back and the.reason I say this for Laughs many times.just patients find it hard to just sit.up in the bed you might want to do it.when you're getting the patient ready to.get up to the chair so when I lift in.I'm gonna listen side to side and I'm.going to start at the very top and you.can take some deep breaths in and out.through your mouth.I was on side to side.I listen to a whole breath in and out in.each section all the way down the whole.long.all right way down all the way down to.here side to side and as I listen I.don't want to put my stethoscope right.on the stop spine I put it next to the.spine and I don't want to put it right.on the scapula so I listen side to side.like this all right now the last thing.that you would do as part of your.assessment you can come on back is that.if your patient mr. Raven is up and.about and moving around and he just came.in through the emergency room last night.so I'm not terribly concerned about his.skin but if it's an older patient or.someone who came from long-term care who.has been here in the hospital I would.make sure to take a really good look at.the skin particularly the pressure.points like the heels the coccyx the.hips and that would conclude our.physical assessment you have any.questions for me sir I have no questions.at this time.all right thank you.

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Assessment Form Of Patient FAQs

Here are some frequently asked questions along with their answers to clear up the doubts that you might have.

Need help? Contact support

Can you put a soldier out of his misery?

The Argentine soldier at Goose Green in the Falklands War who was shot by a British Army medic was in the middle of a large ammunition fire and despite strenuous efforts to pull him free, could not be extricated. He was therefore simply going to burn to death with no possibility of mitigation. The medic however was in fact disciplined. Although not eventually convicted of murder, his career progression was effectively ended by his humanitarian action. The reasons for this are as others have argued. In war you take many life and death decisions, usually instantaneously. The secret to future sanit Continue Reading

Have you ever laughed when a doctor told you a diagnosis?

Yes. I had taken my 10 year old daughter in because she had a cold that just didn’t seem to be getting any better after two weeks. A physicians’ assistant at the clinic (our regular family doctor’s office) listened to her breathing and said, “You know she has asthma, right?” I looked him straight in the eye and asked, “Acute or chronic?” He got all flustered, stammered a bit and said, ”Oh? Well, ummmm …acute.” Then I couldn’t hold it in any more, and laughed. I am sure many won’t understand. See, this ‘almost a doctor” was having his “I am God” moment. He wanted me to bat my eyelashes, be all concer Continue Reading

Why do patients have to fill out forms when visiting a doctor? Why isn't there a "Facebook connect" for patient history/information?

The NHS now keeps the populations care records on a central database ( spine) ,access by any authorised personnel / doctor within the UK. The patient only has to provide security answers to ensure the correct patient information is been accessed.

How can I fill out Google's intern host matching form to optimize my chances of receiving a match?

I was selected for a summer internship 2016. I tried to be very open while filling the preference form: I choose many products as my favorite products and I said I'm open about the team I want to join. I even was very open in the location and start date to get host matching interviews (I negotiated the start date in the interview until both me and my host were happy.) You could ask your recruiter to review your form (there are very cool and could help you a lot since they have a bigger experience). Do a search on the potential team. Before the interviews, try to find smart question that you are Continue Reading

What are some misconceptions that people have about doctors?

If they don't prescribe the patient a drug (medication) they are bad doctors! Some occasionally have this type of thinking. No medication=waste of time= bad doctor

Why are patient forms at hospitals such a pain to fill out?

Basically, it is simply due to fear of litigation. A sad but a necessary truth in our current climate. We offer the very best standard of care, we achieve the best standard of care. But, we constantly have to look over our shoulders to ensure that safe practice has been provided, even when we are certain that is has. Times have changed, am quite glad that I am moving towards my retirement. No professional seems to be totally trusted any more.

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