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Physical Assessment
This section must be completed by the stated due date/time and given to your instructor.
Assessment Findings
Safety Fall risk: PT is receiving diphenhydramine (Benadryl) 50 mg injection IV 4 times
daily; assess for drowsiness. Schmid score: 1
Skin/Wounds Location of wound: posterior- sacrum/coccyx, red, open-to-air; encourage turning
q 2 hrs. Head to toe rash with itching. Skin is intact, hot and red. Diaphoresis.
Elastic turgor. Braden scale: 23.
Respiratory RR: 20 @ 0700 & 20 @ 1100, unlabored. Dyspnea upon exertion. Chest is
symmetric. Rales/ fine crackles noted bilaterally on lower bases. No wheezing. No
use of accessory muscles. Productive cough with sputum. Occasional oxygen use
when pulse oximetry is below 90%: 2L, nasal cannula. Incentive spirometry @
1030: 1250 mL.
Cardiovascular HR: 100 @ 0700 & 83 @ 1100. Rate and rhythm appropriate for age. S1 & S2
audible, no murmurs noted. Carotid, radial, dorsalis pedis, and posterior tibial + 2
bilaterally. Capillary refill: brisk. No edema or JVD.
Gastrointestinal Soft, non-tender. No masses or hernias. Last BM 9/1/15; approximately 0930. No
pain or discomfort.
Genitourinary PT is continent. Two urine occurrences @ 0830 & 1310; unmeasurable. Urine is
clear, yellow/straw, with no odor.
Neurological Alert, cooperative, appropriate affect & judgement. Mood appropriate. A&Ox4.
Speech clear. CNs intact.
Musculoskeletal Gait steady. Grips 5/5 equal bilaterally in upper and lower extremities. Dorsi/
plantar flexion equal 5/5 bilaterally.
IV Lines Peripheral IV Left Antecubital 22 G: removed 1143 by Ally, RN. Infiltration:
Drains/Equipment swelling and pallor, IV catheter was visibly dislodged from the vein.
Peripheral IV Right Antecubital 22 G: inserted 1155 by Ally, RN. IV site free of
redness and PT reports no pain. IV line is patent and fluids are infusing at 100
mL/hr of 0.9% Sodium Chloride.
O2: 2L, nasal cannula.
Being Skillful: B D A E
Reflecting:
Evaluation/Self-Analysis: B D A E
Commitment to Improvement: B D A E
Summary Comments: