Question: PHYSICAL ASSESSMENT ON A PATIENT WITH LIVER FAILURE: MAKE IT UP BUT MAKE IT RELEVANT TO A PATIENT WITH LIVER FAILURE. Student Name: Date: Date Of Admission: Patient Initials: Height: Weight: Allergy: General Appearance: State Of Nutrition: Thin, Frail Or Obese Comfort Level: Without Distress Facial Features/Body Structure: Posture, W/C, Standing; Symmetrical…

Question: PHYSICAL ASSESSMENT ON A PATIENT WITH LIVER FAILURE: MAKE IT UP BUT MAKE IT RELEVANT TO A PATIENT WITH LIVER FAILURE. Student Name: Date: Date Of Admission: Patient Initials: Height: Weight: Allergy: General Appearance: State Of Nutrition: Thin, Frail Or Obese Comfort Level: Without Distress Facial Features/Body Structure: Posture, W/C, Standing; Symmetrical…

PHYSICAL ASSESSMENT ON A PATIENT WITH LIVER FAILURE: MAKE IT UPBUT MAKE IT RELEVANT TO A PATIENT WITH LIVER FAILURE.

Student Name:                      Date:                       

Date of Admission:               Patient Initials:          Height:                      Weight:                      Allergy:

                                                            

General Appearance:

State of Nutrition: Thin, frail or obese

Comfort Level: without distress

Facial Features/Body Structure: Posture, W/C, standing;Symmetrical features

Cardiovascular:

Heart rhythm: Regular, irregular, palpitations, skippedbeats

Rate per minute

Heart sounds: Distinct S1/S2; extra sounds S3/4:

Peripheral pulses: Note strength & rhythm, equality

Edema: Location, dependent, pitting (grade on scale of +1 -+4)

Capillary refill: slow, brisk, < 2 secs

IV: Location of site, solutions/site condition (redness,swelling, temperature)

VS: Temperature (oral, axillary, rectal, tympanic), Pulse(apical),BP, respiration rate (depth)

General Appearance/Subjective:

Cardiovascular:

VS:

Neurological Status:

Level of orientation: alert & oriented to person, place,time/date/year, event.

Alert & oriented to number of variables = AO x1, x2, x3,x4

Pupillary reaction, ocular movement, PERRLA (pupils equallyround, reactive to light/accommodation)

Neurological:

Skin:

Skin tone/variations: (pink, pale, ruddy, light/dark tan/brown,olive tones, jaundice, cyanosis, hypo/hyperpigmented areas.

Temperature/character: Warm/cook, dry/clammy

Texture: Smooth firm with even surfaces

Thickness: Epidermis uniform with increased thickness tosoles/palms

Edema: Name, location and grade from None to 4+

Turgor: tenting x number of seconds or non.

Vascularity: bruising/tattoos

Lesions/Moles/Scars: Color, elevation, pattern or shape, size incm, location/distribution, exudates

Skin:

Hair/Nails/Teeth/Mucous Membranes:

Hair: Color, thick/fine, straight/curly, distribution

Nails: Thin/Thick, pink/yellow, smooth, uneven, 160 degree orless contour, cap refill immediate or number of seconds

Teeth: present or missing, condition, color, plaque, dentures,bridges, breath odor

Mucous Membranes/gums/moist/dry/cracked/pink/pale

Hair/Nails/Teeth/Mucous Membranes:

Physical Examination (continued)

Musculoskeletal System:

ROM: Full range of motion, note number of degrees; describedeficits and compare to opposite side (hemiparesis, hemeplegia,contractures)

Gait: Base width= shoulder width, stagger, stumble, shuffle vs.accurate foot placement & balanced movement, symmetric armswing; if only short distance, note distance or number ofsteps.

Musculoskeletal System:

Respiratory System (thorax/lungs):

Color shape and configuration of chest wall

Quality of respirations

Auscultation: Clear to auscultation (CTA); wheezes (horsewhistling) rales (crackles) rhonchi (coarse rattling) note locationof sounds and upon inspiration or expiration.

If patient is on mechanical ventilation, then need allventilator settings.

Respiratory System (thorax/lungs):

Abdomen:

Contour: Flat, scaphoid, rounded, protuberant

Shape: symmetry, bulges, masses

Auscultation: bowel sounds x 4 quadrants

Hypo/normo/Hyperactive and note region

Palpations: No signs of tenderness and abdomen firm, softhard

Last bowel movement: Size, color & consistency

Diet: type of diet order, percentage patient ate, breakfast& lunch

Abdomen:

Urinary/Genitalia:

Genitalia: Color- pink, inflammation, lesions, scars

Irritation: any itching, discharge, pain/tenderness

Urination: Continent, incontinent, Foley Catheter: (type ofcatheter – indwelling or suprapubic or condom catheter), anyvoiding schedule

Urinary/Genitalia

Psychological:

Facial expression: eye contact, smiling, crying

Mood/Affect: Cooperative, flat affect

Speech: articulation is clear/understandable

Interaction: developmentally appropriate

Personal hygiene: clean

Psychological:

Laboratory/Diagnostics:

  1. Why is your patient getting these labs? (Diseaseprocess/diagnosis)
  2. Why might the values be abnormal?
  3. How might the abnormal value be corrected?
  4. Should additional labs/diagnostics be obtained and if so,when?

Laboratory/Diagnostics:

Date:            Test:          Finding:            Range:

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