making entries in the clinical record must indicate the time and date and sign their name and rate or rank. The following self-questioning technique is a good guide to assist you in developing proficiency in assessing and reporting patient conditions.
General appearance:
.Is the patient
..of average build, short, tall, thin, or obese?
..well-groomed?
..apparently in pain?
..walking with a limp, wearing a cast, walking on crutches, or wearing a prosthetic extremity?
Behavior:
.Does the patient
..appear worried, nervous, excited, depressed, angry, oriented, confused, or unconscious?
..refuse to talk?
..connect thoughts appropriately?
..lisp, stutter, or have slurred speech?
..appear sullen, bored, aggressive, friendly, or cooperative?
..sleep well or arouse early? sleep poorly, moan, talk, or cry out when sleeping? join in ward activities?
..react well toward other patients, staff, and visitors?
Position:
.Does the patient
..remain in one position in bed?
..have difficulty breathing while in any position?
..use just one pillow or require more to sleep well?
..move about in bed without difficulty?
Skin:
.Is the patients skin
..flushed, pale, cyanotic, hot, moist, clammy, cool, or dry?
..bruised, scarred, lacerated, scratched, or showing a rash, lumps, or ulcerations?
..showing signs of pressure, redness, mottling, edema, or pitting edema?
..appearing shiny or stretched? perspiring profusely?
..infested with lice?
Eyes:
.Are the eyelids swollen, bruised, discolored, or drooping?
.Is the sclera clear, dull, yellow, or bloodshot?
.Are the pupils constricted or dilated; are they equal in size; do they react equally to light?
.Does the patient complain about pain; burning; itching; sensitivity to light; or blurred, double, or lack of vision?
.Are the eyes tearing or showing signs of inflammation or discharge?
Ears:
.Does the patient
..hear well bilaterally?
..hold or pull on his or her ears?
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