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9 Cards in this Set
- Front
- Back
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First time visit. |
Introduce yourself. Ask for their full name and BoD, where they are (place), what time and date, who they are with, why are they here. |
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Allergies |
Ask if they are allergic to food, drug, or other substance. Write down the allergy in detail. If they cant remember the exact detail, just write on the side the allergy like allergic to medication (they dont remember which medication.) |
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V.s |
Check for vital sign. Pulse rate. |
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Head to toes assessment. (Face) |
Let them know your checking their head. Check for baldness-alopecia observe Palpate (touch) Head- lighty touch the patient head to check for bumb if they have an injury to the head. (Normal side- normocephalic) (Enlarge head- hydrocephalic) No hematoma-bruising. Check for baldness-alopecia. Check if the hair is healthy.
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Head to toes assessment. (Face) |
Let them know you're going to check their eye. Check the sclera. White- anicteric sclera Red- reddish sclera if u have conjunctivitis. Yellow- icteric sclera. Dust (not yellowish or white)- dirty sclera. Check for pupillary reaction. Have them look straight while you point a light to their pupil with a light on the side away from their pupil to their pupil and away from their pupil.( do it for both eyes). Check if their eye dilate or shrink. Normal size for pupil is 4 mm. Tell them to look at the tip of a pen. While you move the pen close to them and back away slowly to check if their eye movement is functioning. (Convergence) |
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Head to toes assessment. (Face) |
While you check their eyes. Also check for their face. Any skin lesions. Like mole,acne, birth mark. color of their skin. Any unusual pig mention (Red when they have hypertension or pale-when in pain) Check for facial symmetry-equal both left and right of the face. (Patient have stroke, they can have shallow nasolabial fold. The line mark between nose and mouth. Check if skin is dry. Check for nasal deviation. (Bend) Nose is intact. Neurological deficit- ask if they can feel.
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Head to toes assessment. (Neck) |
Tell them you're going to check their neck. (Explain what you're going) Observe the neck like if theres more pigmentation... like for pregnant and the one that use steroids. You palpate the neck. Go to their back and with two fingers. Put your fingers on their side of the thyroid gland. If it's big or not. Have them shallow to check if its it's going upward. Palpate for any lump so Check if their sternocleidomastoid from top sliding down if they have bump on their lymph. Enlarge lymph node- positive lymphadenopathy. Located on the cervical. |
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Head to toes assessment. (Chest) |
Check for bump chest- pigeon chest. For patient with copd. barrel chest- chest becomes round. Make them take a deep breath. See if its symmetrical chest equal on expansion. (Tactile fremitus) Put palm of your hand to their back or front chest and have them say 3 3 3 loud and fast. Listen for vibration if there both are equally vibrating. *Percast-tapping. Use stethoscope. Listen to see if they have whizzing- abnormal sound(incomplete narrowing in the lower airway). Crackle or rales-too much secretion. Moist rales- mucus secretion in the lung. Course rales- more water in the lung. (Anterior) Check below clavicle, side of the nipple, below the nipple and side of body to the lower ribs. (Posterior) check the top of your scapula, side of the scapula, bottom and side of the body. |
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Head to toes assessment. (Abdomen) |
Dorsal recumbent position Infection Observe the patient if they have scars. Check if their stomach is flat or round. Skin color, prominent abdominal vein Bend the knee to relax the abdominal muscle. Measure the abdominal circumference. Look for hernia. Asculation-listen to sound of the natural bowel sound from right, up, left, down. 1min per quadrant. Percaution- tap the rib to the Abdomen. Palpale-Put your finger tip on the end of the ribs to check for liver or spleen size. Ask to take a deep breath. Enlargement of liver- hepatomegaly Enlargement of spleen- splenomegaly |
