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:
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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: |
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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: |
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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: |
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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)
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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: |
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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): |
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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: |
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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 |
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Psychological: Facial expression: eye contact, smiling, crying Mood/Affect: Cooperative, flat affect Speech: articulation is clear/understandable Interaction: developmentally appropriate Personal hygiene: clean |
Psychological: |
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Laboratory/Diagnostics:
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Laboratory/Diagnostics: Date: Test: Finding: Range: |
