Charting the Nursing Assessment

by Samantha Rhea, MSN, RN

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    00:04 We've just done a physical assessment on our client, Brandon.

    00:07 I'd like to show you an example of how we might chart that or what a charting might look like on the patient.

    00:14 So we've got a male client with the age of about approximately 30 years old.

    00:19 Now on general appearance, his overall body build is appropriate and within normal limits for a height a 6 foot and weight of 190 pounds.

    00:30 Now, when we are doing assessment on our client, Brandon, his facial expression was calm.

    00:35 He was cooperative and willing to answer questions.

    00:39 Now, when we're taking a look at Brandon's neurological status, let's take a look at his level of consciousness.

    00:46 So he was alert, awake and responsive to questions.

    00:50 And Brandon is oriented times four.

    00:53 So he was oriented and knew his name, his date of birth, where he was, and also his chief complaint.

    01:01 He was also responsive to voice.

    01:03 So we're overall looking at Brandon's head.

    01:06 He did not complain of a headache.

    01:08 So that was great.

    01:10 Also, when we took a look in his ears, we didn't see any drainage, any scabs, any the issues there.

    01:16 And it was within normal limits.

    01:18 He also does not use any assistive devices for his hearing.

    01:22 Now, moving down to Brandon's mouth, his teeth were healthy.

    01:26 They were intact.

    01:28 Also, his mucous membranes were moist and intact as well.

    01:32 And a general appearance for his skin on his head was pink and intact.

    01:37 When we focus in on Brandon's eyes, he had good vision and good visual eyesight.

    01:43 We take a closer look at his pupils.

    01:45 They were equal, round and reactive to light.

    01:49 And we had a consensual response, which is positive.

    01:52 Brandon's pupil size before the pinlight was 4 millimeters.

    01:57 And after the light we documented at 2 millimeters.

    02:01 Now, moving from Brandon's head to his neck, we check to make sure we don't see any jugular vein distension because we do not want to see that in a healthy patient.

    02:11 And this was not visible.

    02:13 Now, after we've assessed Brandon's neck, we're going to move down to the chest.

    02:18 So we assessed Brandon's heart rhythm.

    02:21 It was regular and there were strong sounds of S1 and S2.

    02:25 Now, when we're documenting respirations, for Brandon, they were regular, even, unlabored and symmetrical.

    02:33 Now in auscultation, when we listened to Brandon's lungs, they were clear in all upper and lower lobes anteriorly and posteriorly, and Brandon didn't have any cough.

    02:45 Now, when we move down to Brandon's arms on assessment, his hand grips were equal and strong.

    02:51 And we rate that at a 5 plus.

    02:54 We were also able to check Brandon's circulation with his radial pulses.

    02:59 And those were both palpable on the left and right radial pulse.

    03:04 And checking capillary refill in both the right and left arm extremity.

    03:09 It was normal.

    03:10 And overall, Brandon's arms, the skin was intact.

    03:13 The color was normal.

    03:15 We didn't see any tinting.

    03:17 That is a sign of dehydration.

    03:19 His skin was warm and it was dry.

    03:22 Now on Brandon's arms that we had, as you just heard, good circulation we saw pulses, a normal cap refill.

    03:30 And he was able to feel when I was assessing his pulse and the temperature was normal.

    03:35 Brandon was also able to move around his arms as active range of motion, and this was within normal limits.

    03:43 Now, moving from chest down to the abdomen, Brandon's abdomen was soft, flat and not distended.

    03:51 Also, Brandon had normal, active bowelsound in all four quadrants.

    03:56 Brandon didn't have any engine tubes or gastric tubes.

    03:59 He was not connected to suction.

    04:02 And he is continent of bowel movement.

    04:04 Brandon reported that he had a bowelmovement within the last day or two, and the stall was within normal limits.

    04:12 Now we move on to the genital urinary Brandon was continent and reports a clear yellow straw yellow urine.

    04:21 Now, when I assessed Brandon's lower extremities, he had strong and equal foot pushes and we would document this at a 5 plus.

    04:30 Now, looking at his circulation, we assessed his pedal pulses and they were palpable in the right and left extremity.

    04:38 We also did not note any edema, so overall Brandon's circulation was good.

    04:45 His color of his extremities were pink and appropriate.

    04:48 He had palpable pulses and his capillary refill was less than 3 seconds.

    04:54 He could feel when I was palpating his pulses and his temperature was appropriate.

    04:59 Brandon did not have any contractures.

    05:02 He did not have any amputations.

    05:05 He also was able to turn himself set up independently.

    05:09 He reports that he's able to walk in the independently and set up in the bed by himself.

    05:14 Now, overall, when we're looking at skin appearance, Brandon did not have any wounds that we noted on the assessment.

    About the Lecture

    The lecture Charting the Nursing Assessment by Samantha Rhea, MSN, RN is from the course Nursing Assessment: Demonstration.

    Included Quiz Questions

    1. Name
    2. Chief complaint
    3. Date of birth
    4. Current location
    5. Health care provider's name
    1. Bilateral palpable pedal pulses
    2. Intact tympanic membranes to both ears with no drainage or excessive cerumen
    3. Jugular vein distension
    4. Good air entry to anterior lung lobes, inspiratory crackles to posterior lobes
    5. Bilateral lower limb strength of 1+

    Author of lecture Charting the Nursing Assessment

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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