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    The document provides guidance on performing a thorough patient assessment using a systems approach. It recommends starting with the patient's history, then assessing each body system from head to toe, including neurologic, cardiac, respiratory, genitourinary, gastrointestinal, and intravenous access. The writer emphasizes beginning the assessment before speaking to the patient by observing their appearance, work of breathing, temperature, and color. With practice, assessments can be completed quickly and accurately using a consistent method.

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    The document provides guidance on performing a thorough patient assessment using a systems approach. It recommends starting with the patient's history, then assessing each body system from head to toe, including neurologic, cardiac, respiratory, genitourinary, gastrointestinal, and intravenous access. The writer emphasizes beginning the assessment before speaking to the patient by observing their appearance, work of breathing, temperature, and color. With practice, assessments can be completed quickly and accurately using a consistent method.

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    7 views2 pages

    Pe

    Uploaded by

    Ace Magbanua
    The document provides guidance on performing a thorough patient assessment using a systems approach. It recommends starting with the patient's history, then assessing each body system from head to toe, including neurologic, cardiac, respiratory, genitourinary, gastrointestinal, and intravenous access. The writer emphasizes beginning the assessment before speaking to the patient by observing their appearance, work of breathing, temperature, and color. With practice, assessments can be completed quickly and accurately using a consistent method.

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    of 2

    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.
    Allergies: PCN/Sulfa.

    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. <10 cc
    residual. Tolerated feeding well. BM x1 QD.

    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..

    A. Head (Skull, Scalp, Hair)


    B. Face
    C. Eyebrows, Eyes and Eyelashes
    D. Eye lids and Lacrimal Apparatus
    E. Conjuctivae
    F. Sclerae
    G. Cornea
    H. Anterior Chamber and Iris
    I. Pupils
    J. Cranial Nerve II (optic nerve)
    K. Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
    L. Ears
    M. Nose and Paranasal Sinuses
    N. Cranial Nerve I (olfactory Nerve)
    O. Neck
    P. Thorax ( Cardiovascular System)
    Q. Breast
    R. Abdomen
    S. Extremities

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