Physical Assessment Narrative
November 22, 2014
Client resting in semi-fowlers position. Hand hygiene performed and verification of client by two identifiers (Name, DOB) are matched with I.D. band to confirm client. Client assessed for allergies and concerns and reports no concerns or allergies. Client is Ox3, LOC is alert, shows PERRLA, and EOMS intact in all fields. Glascow Coma Scale assessed to be a perfect 15. Client grips are 5/5 (B) in hands ...view middle of the document...
Client has intermittent IV in left antecubital region with no fluid intake and client asked if he had anything to drink within last couple hours and he states “I’ve had a 12oz coke” (I said mL in video and meant to say Oz). Intake documented to be 360mL. Client voids using BSC. 200mL of clear, amber urine present in BSC and documented as output. Radial and pedal pulses are palpated and found to be 2+ (B). Client asked about diet and he states he is on a regular diet. Heart sounds auscultated without extra heart sounds and apical pulse assessed to be 66 regular. Respiration rate of 16 with eupneic pattern. Bowel sounds auscultated to be normoactive in all 4 quads. Lungs clear to auscultation in all 5 fields A-P-L. Client wears no corrected lenses/glasses, or hearing aids and no drainage from eyes or ears are noted. ROM full in all areas and gait appears to be steady. IV site appears clean, dry, and free of infiltration. Client safety is assessed and SR up x3, call light in reach, bed alarm green, bed lowered and locked. – MT, JSSN
Things I forgot:
- capillary refill and skin turgor.
- appearance of abdomen
- I didn’t state whether client was on O2 or room air.
- chest diameter
- speech and affect