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PHYSICAL ASSESSMENT

Student Name: __________________________________________  

PROCEDURE

Satisfactory

Unsatisfactory

1.

Verifies the physician’s order for respiratory care and gathers any pertinent information from the patient’s medical record:

Patient history and physical

Consultations

Physician orders

MD Progress notes, Respiratory Care/Nursing notes

Laboratory data

Pulmonary function results

Blood gas results

Imaging studies e.g., Radiograph, CT, MRI

Monitoring data, e.g., Pulse oximetry, ECG

2.

Introduces self to patient, verifies the patient’s identity, assesses the patient’s learning needs and explains the purpose of his/her visit in terms/ways the patient and/or family can understand

3.

      Washes hands using the appropriate hand-hygiene procedure and

      initiates standard and/or transmission based precautions

4.

Performs a patient interview to collect and evaluate pertinent clinical information:

a.

Level of consciousness and orientation, emotional state, and ability to cooperate

b.

Level of pain

c.

Presence of dyspnea, sputum production, and exercise tolerance

d.

Social history, e.g., smoking, substance abuse

e.

Observes facial expressions and body positions for clues about the patient’s symptoms

5.

Measures/Assesses vital signs:

Respiratory rate

Pulse

Blood pressure

Temperature (from flow sheet)

Pulse oximetry

6.

Examines the head and neck:

Mucous membranes

Jugular vein distention

Tracheal deviation

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