Clinical Assessment

Satisfactory Essays

I did assessment on my daughter. I walk into the room and my first assessment was her safety and the environment she is surrounded by. I washed my hand and introduce myself and what I will be doing to the patient, and ask the patient for her name and date of birth. I gave a privacy and started to check for vital signs. Vital signs: Oral temp- 98.7 degrees Fahrenheit Radial pulse-67 beats per minutes Blood pressure- 96/60 Respiratory- 14 breath per minutes Inspection: I am looking to see if there is any abnormal vision, hearing, sensing, smelling, or even if I notice any discoloration of the skin, texture of the skin, and lesions, or any redness of the skin and hair texture. I would document my findings, and if I notice a problem then …show more content…

I would also feel for the skin’s texture, temperature, elasticity, moisture and tenderness of the area of the body. As I am checking the upper and lower extremities, I would also check for palpation. I would palpate the tender area last and ask how painful the area is and document everything. Abnormal finding would need a further evaluation. Percussion: I would put my two fingers on the area of my patient and tap directly on the body part and ask my patient if they are in pain, and I would also focus on their verbal and non-verbal to determine how painful the area is. This technique would help me notice any tenderness, shape, and position of the organs. I have checked the abdomen and is not solid and it is not full of gas or fluid. My finding would be documented. Auscultation: I would be in a quiet room so that I hear the sound of the heart, lung, and bowl movement clearly with my stethoscope. I would first expose the area then I would use the diaphragm part of the stethoscope. I would put the diaphragm part of the stethoscope hear the high pitch sound of the right 2nd interspace, left 2nd interspace, left down sternum, and apex of the heart. Then I would put the bell part of the stethoscope lightly on the skin to hear the low pitch sound of the mitral and tricuspid

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