Assess skin, continence, ability to turn self.Plan ahead if you need help to turn the patient – get UAP’s in the room. BACK → Have your patient turn to one side.A patient who can bend both knees should leave them bent for the next step!.Patient should be reporting pain with movement.Range of motion – “ Can you bend your knees?”.Strength → “ Push down on my hands like a gas pedal” – “Pull your toes toward your head” – “ Lift your legs off the bed, don’t let me push them down”. ![]() Can put hand on joint while this is occurring to assess for crepitus.Patient should be reporting any pain with movement. ![]() Range of motion → “ Can you put your arms out to the side? Now over your head?”.Strength → “ Lift your hands up like you’re stopping a bus – push against me” – “now, pull me towards you”.Skin, nails, edema, temperature, moisture.Quick way to get both hands in front of them – you can then move to pulses and the rest of strength.Feel for tight, firm, or distended abdomen.Watch for grimacing or guarding that may indicate pain.Palpate abdomen x 4 quadrants looking for obvious masses or tenderness. IF ABNORMAL → percuss (dull or distended may = blood).INSPECT → skin, symmetry, distention, hernias.If you hear active bowel sounds right away, go to next quadrant – must listen for full 5 minutes to confirm absent. Just breathe normally for now.” – “Now take a deep breath in and out when you feel my stethoscope on your chest” for lung sounds Stethoscope ON → Listen AND Inspect simultaneously “ I’m going to listen to your heart, lungs, and belly now.ASK: “ Any pain or issues with your head, neck, jaw, or ears?” If NO – MOVE ON!.Neck ROM (they should tell you if it hurts).Then perform visual fields with the cardinal directions (“Follow my finger with just your eyes”). Then ask patient “Turn your head to the left, now to the right” -while you look at/in their ears briefly. Look quickly in nose and mouth (“Open your mouth, stick out your tongue”). Pen Light → Assess pupil response (PERRLA) (“Look straight at my nose”).Allows you to be constantly assessing for pain throughout assessment.Tell the patient: “I’m going to start the physical part of the assessment, if anything I do or ask you to do causes you pain, just let me know”.Further idea of affect, emotions, LOC, verbal response, speech quality, etc.Orientation questions: “Just a few questions we ask everyone – Can you tell me your name? Can you tell me where we are right now? Can you tell me what month it is? What brought you into the hospital?”.“I need to do a quick assessment to start the shift, is that okay?”. If they are asleep, call their name, then gently shake, and progress to deeper stimuli as needed. Stethoscope should be on bare skin for most accuracy.Remember to ALWAYS inspect skin throughout assessment and to remove gown/clothing!.Underlined words are equipment you will need. ![]()
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