Hello. My name is ____ and I will be completing a comprehensive assessment today as part of my WGU C350 requirement.Hi there. My name is ___ , and I’m going to be doing a head-to-toe assessment for you today. For the record, can you state your name please? Thank you. And will you please just confirm that you are voluntarily allowing yourself to be videoed as part of this assessment?And Maddie, why are you here today?Physical? No complaints, concerns, no other issues? Just here for a routine healthy physical exam?Okay, before we get started, any significant medical history for yourself? Any chronic illness, diseases, surgeries? Are you taking any medications – either prescribed or OTC? Any herbal supplements?Do you have any allergies? To medications or foods, etc.Now, looking at your family – is there any significant medical history of illness, disease, surgery, early deaths? Mom? Dad? Siblings? Children? Grandparents?And for your personal social history – are you married? Do you have any children? What is your occupation? Tell me about your social habits – do you drink? Smoke? Do any recreational/street drugs? Tell me about your exercise habits.Are you up to date on your immunizations? Did you get a flu shot this season? Okay, give me just a moment while I make some notes here on your chart.For the record, can you please state your height and weight.Now I’m going to go ahead and do your vital signs first, then we’ll proceed with the head-to-toe examination. Is that okay?BP cuff – you’re going to feel this squeeze/hug your arm for just a few seconds. Let me know if it’s too uncomfortable. Your blood pressure is ____.Now I’m going to check your temperature. Your temperature is ___.Now I’m going to check your pulse. You’ll feel my fingers on your wrist, right here your radial pulse. I’ll use the first 30 seconds to assess the radial pulse, and the second 30 seconds to assess/count her respirations, without her knowing, to obtain a normal resting respiratory rate. Your pulse is ___. Your respirations are ____.When I walk into a room, my assessment already begins – with an observed overview of skin, appearance, etc. Just by looking, I can see that she has good oxygenation, pigment/skin tone is normal, no obvious deformities or abnormalities noted.Now, I’m going to touch you and begin my assessment. I’m just examining your skin to make sure you don’t have any lesions, rashes, abnormal moles, masses, etc. I’m also assessing the warmth of your skin bilaterally, which can help me determine if there are any perfusion abnormalities. Skin appears to be normal, no significant signs of dehydration, turgor is normal, no tenting or edema noted.Looking at your hands and fingernails, examining your capillary refill – which is brisk and <3 seconds. Good.
I will move on to your head/face/neck. Can you please smile for me? Look surprised? Frown for me? Now you’re going to feel my hands on your head/scalp. As I’m doing this, I’m looking for hair distribution, dryness, lesions, open areas, feeling for lumps/bumps, checking her cranium and it’s normocephalic.
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- Fall '18
- pulse, Maddie