Example Of Nursing Physical Assessment

During procedure nurse is usually passing instruments, making sure equipment is set up and ready to go, assisting with taking radiographs, taking care about patient’s escort during taking radiographs, making sure patient is comfortable and calm, processing x-rays, also working length have to be recorded in the patient notes either paper or digital or both

Only when it is absolutely necessary should a catheter be inserted into a patient. Every patient is assessed for the need for a Foley catheter. If the Foley is inserted, assessments are also then done daily to see if the need is still valid. If the reason is not justifiable the catheter must be removed from the patient (Joint Commission releases new NPSG for CAUTI, 2011). Nurses must follow guidelines while inserting indwelling catheters as well. Aseptic technique is critical to maintain during this process. The use of sterile equipment and a sterile procedure helps to reduce the risk of CAUTI. If in any way the catheter becomes contaminated during the process of insertion, the nurse should discard of the entire catheter and start with a new, sterile kit. Proper hand hygiene is very important before and after contact with indwelling catheters to decrease risk of infection. Maintenance of a close drainage is system is also important that way bacteria are not able to get in and cause infection (Revello & Gallo, 2013). Decreasing the number of times Foleys are inserted and how long they stay in for can help reduce the risk of CAUTI since the longer a Foley stays in, the higher the risk of infection becomes. Nurses must keep the catheter line patent, with no kinks to allow urine to flow freely through into the collection bag. When a urine sample must be obtained it must be done in a sterile

Nurses are best positioned to make the decision to remove catheters as they are in direct and constant contact with the patient.

Mr. P’s vital signs and diagnostic studies are as follows: Blood glucose level 700mg/dL, Blood Pressure 90/60mm Hg, Heart Rate 128 beats/min, Respiratory Rate 34 breaths/min, Temperature 100.8 F, Serum pH 7.26, Serum HCO3 10 mEq/L, BUN 40 and Creatinine 3.5.

The contrast administration is determined either by the hospital protocol or the physician. It also depends on the type of test and/or the anatomy of the patient that is to be examined. The facility where I work at, perform two kinds of IV contrast studies and those studies are dependent on the need and/or condition of the patient. It is the job of the technologist to screen the patient to determine the type of contrast to be used.

19) The nurse is running an IV on a patient and notices a large welt forming where the IV is

Once everyone finishes interviewing the patient, the anesthesiologists bring the patient to the operating room. In the room, the nurse again confirms, if she has received the right patient by checking the patient 's identification band and by asking the patient. Before prepping the surgical site, the nurse, anesthesiologist, and the surgeon confirms the patient, the surgical site, and position of the patient. The nurse does the surgical "Time Out," once the patient is draped, and just before the incision. During time out, the nurse will loudly announces the elements of time out; correct patient, verifying the correct site and laterality, correct position, correct procedure, availability of correct implants or equipments, availability of pre-op radiographs, any prophylaxis antibiotics, and allergies.

When we first got this assignment I wasn’t sure about this exercise. I kept thinking to myself what is nine boxes with words going to do for me. Is this going to be a waste of time? Surprisingly it wasn’t that bad to complete. As I got going and started thinking of examples and words to fill the spaces I flew through it. My conclusions of the exercise is to continue and keep going from the smaller boxes would kind of be hard. You really need to think and be creative about the words you fill the spaces with.

The patient is a 19-year-old male named Matt. He was being treated for lethargy, excessive thirst, recent unexpected weight loss, fever, and complaints of frequent urination. Matt is a college cross-country runner who is otherwise is healthy. He is currently uninsured and his diet consists of fast food meals and prepackaged meals. Also, he consumes 3-4 beers about 3-4 days a week. Matt is allergic to Penicillin as well as Sulfa Drugs. After the assessment Matt has a temperature of 101.6 F and has a pain level of 4/10 while urinating in which he experiences a burning pain. His skin is warm and dry and has a 1 inch by 5/8th inch skin break on the posterior right ankle that has not healed in 3 weeks. Additionally, Matt was treated once in

This week in clinical I was assigned a 44-year-old male patient who presented to the ER complaining for abdominal pain for the past 10 days and was found to have gallstones. The patient needs a cholecystectomy, but the family wants a second opinion before the patient undergoes this procedure. The patient was alert and orientated x4. The patient said that is pain is 0/10 and that he felt fine. His vital signs were normal. His past surgical history included lithotripsy, which is treatment for kidney stones where ultrasound shock waves are sent to break kidney stones into small particles that can be passed out by the body. The patient was a on NPO diet, something that the patient did not like very much. The patient said that he wanted to drink water, but I told him that he couldn’t because of the NPO diet.

CHIEF COMPLAINANT: Patient is a known diabetic, he has been converted over to insulin, he has been doing very well. His blood sugars are running in the low 100's, in the last month he has had one episode of blood sugar 57, otherwise, has done very well. He watches his diet, he tries to stay active. He has a known prior history of a lung resection for neoplasm, he has not been coughing up any blood. He does has some flem at times he has difficulty clearing. No chills or fever. No chest pain. No swelling in his legs, no leg sores. He sees podiatry every 3 months and he has an eye clinic scheduled for next month.

Abnormal Physical Assessment Findings- Patient N.L had respiratory rate of 26 beats per minute (RR), Blood pressure of 168/98 (BPM), and Oxygen Saturation of 94%, complaining of moderate to severe distressed abdominal pain. Palpating abdomen shows distentions and bowel sounds are absent in the lower quadrants with tenderness in the peri-umbilical area.

Initially the nurse explained him about the need for the fluid therapy, the route of administration and attained the consent from him (NMC, 2015). The nurse also informed him about the need for keeping the measurement on his fluid intake and output. In an adult, the normal urine output is .5ml/ kilogram body weight (Campbell, 2011). Moreover, the nurse assessed his vital signs at regular intervals, which is a clear indication for his health status. In addition to the intravenous fluid, the nurse encouraged him to drink more water for the fast recovery. Furthermore, as the nurse also made him aware of the needs for blood test on the next morning, he felt more informed and respected and made him more adhere with the

First of all, since the patient is in a slightly oblique position, he needs to be straightened and moved up the bed. It is important to move the patient into an upright position so that optimal AP chest X-rays could be obtained (2). In addition, the patient is unconscious and he is not able to cooperate with the examination. He weighs 145kg and the nurse looking after him refuses to help because she is pregnant. Therefore, manual handling would be needed and it should be performed properly to reduce the risk of back injury of staffs (3). Besides, the patient is mechanically ventilated, therefore the positioning should be performed carefully to avoid displacing monitoring devices(2). Meanwhile, it is also important to move the external portions of lines and catheters above the clavicles and off the patient if possible (2). By doing so, artifacts would be less likely to cover disease and cause confusion (1). Moreover, the patient is MRSA positive. Infections with MRSA may increase morbidity, mortality and healthcare costs in ICU patients (4). Therefore, it is important to improve infection control within ICU and hospital-wide screening and

Chief Complaint: The patient complains of dysuria and some abdominal pain for the past 3 days