https://youtu.be/j8JolrO0_QI

https://youtu.be/cnkwnZYzG_s

Assessment and Document( Factors Affecting Health)

AssessmentDocumentation

Neuro –

What date, time, year and place?Pt A&O x4 ,Perlaa, Moves all extremities well

To check cranial nerves 2-12-CN- 2-12 intact

Ask pt to squeeze my hands, wiggle yourask pt about HA, Blurred vision,

Toes, stick our your tongue, smile,dizziness, document denies

Shrug our shoulders, point your toes,

Follow my fingers with your eyes-EOMs

Turn off lights and look at pupils for light

Reflex and accommodation

Cv- listen for heart sounds-and valvesCV-S1,S2, denies CP ,color good with cap refill < 3 sec.

Apple Pie Tastes MMMRate/rhthymHR 88 regular no ectopy , no cyanosis, Skin warm/dry

Check all peripheral pulses bilaterallyno edema noted , All peripheral pulses equal bil 2 +,

Brachial, radial, femoral, popliteal Os sat-97 % ,color adequate

Pedals and post tibias compare and

Document, check cap refill

Check for edema, skin color, temp

moisture

Resp – Check rr, auscultate lung sound inResp -unlabored normal on room air

All 9 lung fields ant- ruq-3 lobes, luq-2lobesall lung fields are clear with equal bilateral breath

Posterior-RUL, LUL, RLL, LLL check for adequatesounds, no use of accessory muscles,

Chest Excursion and use of accessory muscles

Document

GI- Check bowel sounds in all four quadrants checkGi- pt is on reg diet, tol well, has active bowel

Rlq for rebound tenderness, Check for Diet/stoolsound in all quadrants, no rebound tenderness,

Check color , amount and frequency of stoolregular stools daily with no issues of,Constipation nausea or vomiting

G/u-check voiding , amount and colorvoiding clear yellow urine with adequate amts

Skin- document any skin issues, birthmarks

Colors, wounds, any drainage, measure.document intact skin or wound measurement,

Document any incisions,scarsAppearance,drainage, dressings,scarsAppearance

INSTRUCTIONS

Please chick the link above and watch the you tube videos.

There are resources to help to

The other part under is factors affecting health, is another resoures

QUESTION TO WRITE ON

Please go to QSEN website and pick one of the six competencies. Pick one of the Listed KSA-knowledge, Skill and Attitudes and briefly describe how this KSA applies to you as a prelicensure nursing student.