Monday, May 18, 2009

Adult Female Written Assessment

Recently I wanted to give my students a good example of a complete head to toe assessment of an OB patient but was unable to find one on the internet so I typed one up. I would like some help with critique please leave comments to make this a better assessment I am going to work on more assessments for males and females in different age groups. I think that every nurse should be able to write a good complete head to toe assessment I find that I am lacking in this area so I would like feedback. I am requiring my students to write a complete assessment in class, so that they have practice before they are out in the real world. Thank you for your help in advance.

25 year old female pt of Dr. X laying semi fowlers in bed, polite and well groomed. A&O x4 (person, place, time and situation), answers questions appropriately pt denies allergies. Pt states that she is here for routine OB visit, at 37 weeks G3 P1 AB 1s L1. Head: clean hair, well kept, facial features symmetrical, clear speech, PEARRLA, no drainage from eye or ears, mucus membranes moist and pink, teeth in good condition, no observed mouth ulcers. Neck supple, without palpable nodes, no vein distention, pt able to move head in all directions well. Lungs clear throughout, symmetrical expansion with inspiration, no rubbing heard, no cough as also denied by pt. Heart S1 S2 heard, no mummer, strong distal pulses radial, dorslas pedius. Breast symmetrical, without dimpling, or skin lesions, areola symmetrical nipple without cracks or lesions. Pt able to move arms easily, firm equal grips, no edema noted. Abdomen Gravid, although soft, non tender, bowel sounds x 4 quadrants, pt denies constipation, diarrhea, or painPt denies urinary symptoms, denies urgency, frequency, or dysuria, non palpable bladder. Genital Symmetric, no lesions, sterile vaginal exam 1-2 cm, 50% effaced, -2 station. Able to move all lower extremities, 1+pitting edema, 2+pedal pulses. No skin lesions, turgor normal for age.


Theresa said...

homan's sign, clonus, pain scale. Just a couple of extra things but it looks good!

Prisca: said...

I like the mnemonic BUBBLE-HE that an old instructor taught me.
Homans & Clonus

Kind of a chest down approach--but I address neuro with emotions. Anyway, you have a good list going!

Anonymous said...

Looks good! If you are giving it to students, I would clean up typos/errors:

lying not laying
dorsalis pedis
mucous not mucus (mucus is the noun)
murmer not mummer

State of Grace said...

what others have said and vitals, how about FHT's?