General Patient Assessment tool

Patient Assessment Tool

 

System Assessed

Health Promoting Action

Approach/rapport

  • Wash hands pre & post care

  • overall appearance

  • height, weight, build

  • hygiene, grooming

  • body and breath odor

  • facial expression

Vitals

  • Temperature

  • Pulse rate and quality

  • respiration rate and quality

  • blood pressure

  • pain

Hx

  • Reason for contact

  • past medical/surgical history

  • current & past medications

  • sleep/rest patterns

Head and Neck

  • Hair and scalp

  • Hearing aids & glasses

  • Skin: rash abrasions

  • assist with morning care

  • inspect eyes, lids & lacrimal glands

  • inspect ears, nose and mucosa

  • lymph nodes

  • ROM

Neuro

  • Orientation x 3 (name, location, time)

  • PERLA

  • LOC (alert, drowsy, unresponsive)

  • Limb strength (squeeze fingers)

  • Mini mental as needed

Thorax & Lungs

  • Breathing effort & posture (SOB/SOBe)

  • thoracic expansion

  • chest musculature

  • sputum (colour & consistency)

  • auscultation for breath sounds

  • meds = vasodilators, anti-hypertensives

Abdominal

  • Cystology: urine colour, odor, quantity

  • Stool: BM consistency, colour, regularity

  • continence: stool, urine – attends, foley

  • Abdominal masses

  • auscultation: bowel sounds

Musculoskeletal

  • ADL’s and ROM

  • Mobility Aids: walker, wheel chair

  • inflammation, edema, weakness

 

 

Nutrition

  • Diet: minced, puree, fluids

  • Dentures

  • difficulty swallowing

  • allergies

  • mucus membrane moisture

Safety

  • Bed rails up

  • Call bell within reach

  • bed lowest to ground

  • water, juice, kleenex in reach

 

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