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Physical Assessments
nursing two lab assessments
| Question | Answer |
|---|---|
| Disorientation/confusion | NEURO VITAL SIGNS & LEVEL OF CONSCIOUSNESSASSESSMENT Objective data:a. LOC, AAOX4 (Person, place, time & situation)b. Mental status: If client is not oriented X4, note:• If client can answer simple questions such as, “Who is the president?” or “W |
| Hypoglycemia | ASSESSMENT Objective data:a. Actual BG level.b. Is skin cool & clammy? Pallor?c. Vital signsd. Lack of coordination?e. Level of consciousnessASSESSMENT Subjective data:f. Feeling of nervousness or shakiness?g. Blurred vision?h. Fatigue? |
| DIZZINESS | ASSESSMENT Objective data:a. Is client leaning to one side or the other?b. Is client’s gait steady or unsteady?c. ASSESSMENT Subjective data:d. Pain e. Dressing• Vital signs, especially B/P, HR. |
| Immediate post-op period | ASSESSMENT:a. LOCb. V/Sc. Head to toed. Incision (see wound/incision)e. Neuro (see neuro checks)f. O2 saturationg. IVh. Foley (see Foley)i. Pain (see pain)j. Epidural/spinal/blocks5P’s – distal appendagesa. HA with epidural/spinal |
| Tachycardia | HEART RATE & RHYTHMASSESSMENT Objective data:a. Auscultation• Adventitious sounds• Rate• Regular/irregular• Rhythmb. Telemetry #c. Pulse (see pulse)d. Capillary refille. Periphery (skin w/d)f. PacemakerASSESSMENT Subjective data: |
| Restrained limbs | EDEMA – EXTREMITY:ASSESSMENT Objective:a. Location (how high up the extremity)b. Type (pitting/ non-pitting /dependent)c. Pulsesd. Capillary refille. ROMf. 6P’sg. Skin/breakdownh. Skin appearance/colori. Temperaturej. Dietary restric |
| Edema | ASSESSMENT Objective:a. Location (how high up the extremity)b. Type (pitting/ non-pitting /dependent)c. Pulsesd. Capillary refille. ROMf. 6P’sg. Skin/breakdownh. Skin appearance/colori. Temperaturej. Dietary restrictionsASSESSMENT Su |