Mod 3 - General Assessment and Vital Signs Lab Worksheet (1) PDF

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Summary

lab work for health assesment laboratory....

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General Assessment and Vital Signs Worksheet TECHNIQUES Inspection: Perform a general inspection of your lab partner, including posture, movement, facial expression, odors, general skin color Palpation: Practice light and deep palpation techniques Percussion: Practice direct and indirect percussion techniques Auscultation: Practice use of your stethoscope with both the diaphragm and bell Abdomen Heart Lungs Note: these do not need to be documented! HEIGHT AND WEIGHT ASSESSMENT Height (Feet and inches OR centimeters) – measure to the nearest ¼ inch or ½ cm) Weight (Pounds – measure to the nearest ¼ pound) Calculate the Body Mass Index (BMI – round to the nearest hundredth) Weight in Kg Height in meters2

164 cm 162 26.96

Weight in pounds x 703 Height in inches2

Document your conclusions about the height and weight: Your analysis of the data! i.e., what does the BMI tell you? Example: Underweight as evidenced by BMI of 17.23 Conclusions about height and weight: according to the BMI, patient is overweight for their height VITAL SIGNS ASSESSMENT TEMPERATURE Oral Forehead 97.4 Tympanic PULSE RATE 51 RESPIRATORY RATE 22 BLOOD PRESSURE Palpated BP 120 Right arm systolic BP 135 Right arm diastolic BP 40 (first sound) (secondary sound) Left arm systolic BP 140 Left arm diastolic BP 39 (first sound) (secondary sound) ORTHOSTATIC BLOOD PRESSURE: Remember: (1) begin with your partner in supine position, after 5 minutes, take BP and pulse; (2) have her/him sit up, take BP and pulse after 1 minute; (3) have her or him stand up, take BP and pulse after 1 minute) Supine Blood Pressure 115/45 Pulse Rate 69 Sitting

Blood Pressure

120/30

Pulse Rate

30

Standing

Blood Pressure

130/40

Pulse Rate

40

Document your conclusions about the vital signs: Do not repeat them, but give your analysis of the data! i.e., what do the VS tell you? Conclusions about Vital Signs: The patient has ranges that are on the higher end of averages. PAIN ASSESSMENT: If no current pain, state “No pain reported”, Otherwise, describe location, characteristics, severity, duration, aggravating factors, alleviating factors, associated symptoms, effect on function, and conclusions about pain. Conclusions about pain: no pain reported MENTAL STATUS ASSESSMENT: [Mini-Mental Status (MMSE) and Level of Consciousness (LOC)

MENTAL STATUS SCORE Orientation What is the (year)(season)(date)(day)(month)? [5 possible]: 5 Where are we (state)(county)(town) (hospital/clinic)(floor)? [5 possible] 5 Registration: Name 3 objects and ask person to repeat them (repeat until can name all 3 3) [3 possible] Attention and Calculation: Serial 7s (stop after 5 answers) [5 possible] 5 Recall: Ask for the 3 objects repeated in registration. [3 possible] 3 Language Name a pencil and watch [2 possible] 2 Repeat the following: “No ifs, ands, or buts” [1 possible] 1 Follow a 3-stage command: “Take a paper in your right hand, fold it in half, and place it on 3 the floor” [3 possible] Read and obey the following: “CLOSE YOUR EYES [1 possible] 1 Write a sentence Score: (1 possible) 1 Copy a design: Draw 2 intersecting pentagons. Have person copy the design (must have 2 all 10 angles and at least one point of intersection) [1 possible] Level of Consciousness [delete either the shaded box or the unshaded box as appropriate]

◙ □ Alert

◙ □ Drowsy

◙ □ Stupor

◙ □ Coma

Document the MMSE total score and your conclusions about the MMSE results. Do not repeat the data - give your analysis. Conclusions about Mental Status: Patient received a score of 31. Patient was able to perform every task.

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