Charting the Nursing Assessment

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.