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  • Physical Assessment

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    catislandbigred
    151 vizualizări10 pagini
    This physical assessment guide provides a checklist for evaluating a patient's neuropsychological status, speech, behavior, general symptoms, head and neck, eyes, ears, musculoskeletal system, respiratory system, cardiovascular system, peripheral vascular system, gastrointestinal system, renal/urological system, integumentary system, and nail beds. The assessment involves checking for things like orientation, affect, pupil reactivity, bowel sounds, edema, and other physical findings.

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    Physical Assessment

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    This physical assessment guide provides a checklist for evaluating a patient's neuropsychological status, speech, behavior, general symptoms, head and neck, eyes, ears, musculoskeletal system, respiratory system, cardiovascular system, peripheral vascular system, gastrointestinal system, renal/urological system, integumentary system, and nail beds. The assessment involves checking for things like orientation, affect, pupil reactivity, bowel sounds, edema, and other physical findings.

    Drepturi de autor:

    Attribution Non-Commercial (BY-NC)
    Descărcați ca DOCX, PDF, TXT sau citiți online pe Scribd
    Indicator pentru conținut neadecvat
    151 vizualizări10 pagini

    Physical Assessment

    Încărcat de

    catislandbigred
    This physical assessment guide provides a checklist for evaluating a patient's neuropsychological status, speech, behavior, general symptoms, head and neck, eyes, ears, musculoskeletal system, respiratory system, cardiovascular system, peripheral vascular system, gastrointestinal system, renal/urological system, integumentary system, and nail beds. The assessment involves checking for things like orientation, affect, pupil reactivity, bowel sounds, edema, and other physical findings.

    Drepturi de autor:

    Attribution Non-Commercial (BY-NC)
    Descărcați ca DOCX, PDF, TXT sau citiți online pe Scribd
    Indicator pentru conținut neadecvat
    din 10

    PHYSICAL ASSESSMENT GUIDE

    NEUROPSYCHOLOGICAL

    MENTAL STATUS: o Oriented o Person o Place o Time o Date o Alert o Dull Affect

    SPEECH o Clear o Other_______________

    STIMULUS RESPONSE: o Verbal o Touch o Pain

    ENT 1

    BEHAVIOR: o Cooperative o Uncooperative o Combative o Anxious o Depressed o Restless o Unresponsive o Confused (explain)___________ o Other (explain)______________

    GENERAL: o Syncope o Dizziness o Malaise o Seizures o Memory loss o Insomnia o Other______________________ COMMENTS:

    ENT 2

    HEAD/NECK: o Symmetrical o Range of motion o Oral mucosa o Pink o Other_______________ o Moist o Dry o Teeth present condition___ o Teeth absent____________

    EYES: o Drainage o Pupils o Equal o Unequal o React to light o Accommodate o Sclera o White

    ENT 3

    o Jaundice o Other___________________ o Conjunctiva o Pink o Pale o Other___________________ EARS: o Drainage COMMENTS:

    MUSCULOSKELETAL: o Symmetrical muscles o Full ROM o Absence of joint swelling o Full muscle strength o Steady gait o Other______________________ COMMENTS:

    RESPIRATORY: Rate_______________ o Effort

    ENT 4

    o Norma; o Shallow o Hyperpnea o Wheezing o Dyspnea o Apneic periods o Orthopnea o Labored o Painful o Other______________ o Rhythm o Regular o Irregular o Sounds o Equal o Clear o Other COMMENTS:

    CARDIOVASCULAR: o Apical pulse

    ENT 5

    o Regular o Irregular o Rate______________ o Jugular Neck Distention o Pain

    PERIPHERAL VASCULAR: o Pulses RT LT o Carotid_____________ o Radial______________ o Brachial____________ o Femoral____________ o Popliteal____________ o Posterior tibial_______ o Dorsalis pedis________ o Rhythm o Regular o Irregular o Homans o Pain o Blood pressure

    ENT 6

    o Right arm o Left arm COMMENTS:

    GASTROINTESTINAL: o Abdomen o Soft o Distended o Painful o Rigid o Other_________________ o Bowel sounds o URQ o LLQ o LLQ o RLQ o Intake/Appetite o Percentage____________ o Dysphagia o Trouble chewing o Nausea

    ENT 7

    o Vomiting o Weight loss o Weight gain o Other_________________

    Food Intolerances:

    BOWEL HABITS: o Frequency____________________ o Diarrhea o Constipation o Date last BM__________________ o Aids for elimination____________ o Color o Black o Bloody o Other________________ COMMENTS:

    RENAL/UROLOGICAL: o Urine flow

    ENT 8

    o No problems o Urgency o Incontinent o Burning o Hesitancy o Dysuria o Hematuria o Frequency o Other_________________ o Appearance/color_______________ COMMENTS:

    INTEGUMENTARY: o Coloring o Skin o Pink o Cyanotic o Jaundice o Other_________________ o Texture/Turgor o Dry

    ENT 9

    o Moist o Inelastic o Other_________________ o Nail beds o Pink o Pale o Cyanotic o Capillary blanching__sec o Edema o Absent o Pedal o Sacral COMMENTS

    ENT 10

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