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Clinical Prep Sheet

Clinical Prep Sheet

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Published by Linda Kuglarz
physical assessment
physical assessment

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Published by: Linda Kuglarz on Oct 12, 2008
Copyright:Attribution Non-commercial

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12/13/2012

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Head to Toe Assessment
1. Wash hands as as you enter the room2. Introduce my self3. VitalsTake temp orallyTake radial pulse (2nd hand watch)Put hand on stomach while taking the radial pulse (for respirations) (1 full min)Do preliminary palpitory systole (BP) and check auscultatory gap
4. NEURO
What year is this?Could you tell me your name?Could you tell me where you are?Could you tell me why you are here?
5. PEERLA
Check pupils and see if they are round and equal, reactiveShine light from the side to the front and see if they reactCheck for accommodation ( put flashlight near (constrict), put flashlight far (dilate))
6. CARDIAC
While bed is low,check if veins are flatthen put bed to 45 degrees and see if its still flat*if distended, means cardiac failure
7. HEART SOUNDS
Auscultate aortic, pulmonic, tricuspid and apical (check for one full minute)Peripheral pulses ( +1, +2, +3)
8. CIRCULATORY
Check both radial pulse in both wrists for 1 FULL MINUTE.Then do hand strengthCheck for rate, rhythm, symmetryCheck pedal pulses TOP (both) then right and left (tibial pulses)
9. CAPILLARY REFILL
Squeeze all nails (foot and fingers)Check clubbing or cyanosis
10. PERIPHERAL EDEMA
FeetHandsSacrum (turn patient to the opposite side and press sacrum)
11. RESPIRATORY
Raise bed all the way and put table for patient to lean on while sitting up and ask patient to spread his/ hers armsCheck posterior firstOne full breath each time you put the stethoscopeDo not put over bone (know the norms)1
 
12. GI/GU
Put bed down all the way and have her supineCheck condition of the stomachStart at the RLQ (check if sounds are absent, hyperactive or hypoactive)5-20 you should normally hear a gurgleAsk “When was your last bowel movement?”
13. MUSCULOSKELETAL
Check if patient is ambulating by asking him/her if he/she can get up and walk a few steps
14. INTEGUMENTARY
Skin Turgor (< 3s)Pinch down below the clavicle (bilaterally)Pull down bottom lips (see if pink and check for cyanosis)Check conjunctivaCheck sacrum (pinch)Check skin, feet and arm temperature using the back of the hand
14. SKIN BREAKDOWN CHECK
Check the whole body for skin breakdownCheck all bone prominences (hands,feet,sacral, etc.)
15. ASSESSING FOR PAIN
“Are you in any pain?”Where is the pain?How long has it lasted?Does the pain travel anywhere?What makes it feel better?What makes the pain worse?Can you describe the pain? Is it STABBING, SHARP, DULL?On a scale of 1 through 10, 10 being the worst, how would you rate your pain?
16. HOMANS SIGN
Check for thrombophlebitisDorsiflex the patients both feetPain in right calf? (should be no)Pain in left calf? (should be no)
17. CLOSURE
Put side rails upBed in the lowest position“Thank you very much”Is there something else I can do for you? (call light within reach)2
 
STUDENT PREPARATION FOR THE CLINICAL EXPERIENCE
Room #________
Date of Care___________Patient Demographic Information:
Initials________
Age_______
Sex_______
Patient History
(look at Physicians history, physical exam., Consults, Nsg. Admission form, ERrecord, transfer sheet to get this information):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Significant Labs & other tests ordered for today
(explain why it is ordered and why?)
. Withdate test was done. How do these relate to illness? Note trends.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Operative or procedure report findings:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Physician Orders
(look in Kardex & Physician orders)
Diet
( include supplements, tube feedings etc.):__________________________________________________________________________________________________________________________________________________________________________________________
Activity:
___________________________________ Elimination:_____________________________________________________________________________________________________________________________________Therapy
(PT, OT, ST):________________________
Respiratory Therapy Orders:__________________________
________________________________________________________________________________________________________________________________________________________
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