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SCRIPT - ASSESSMENT (AutoRecovered)

The document outlines steps for conducting abdominal, neurological, and musculoskeletal assessments of a patient. It provides examination procedures and questions for inspecting, auscultating, and palpating different parts of the body.

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Angela Shaine Cruz
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525 views5 pages

SCRIPT - ASSESSMENT (AutoRecovered)

The document outlines steps for conducting abdominal, neurological, and musculoskeletal assessments of a patient. It provides examination procedures and questions for inspecting, auscultating, and palpating different parts of the body.

Uploaded by

Angela Shaine Cruz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SCRIPT IN KIDNEY, ABDOMINAL, NEUROLOGICAL AND MUSCULOSKELETAL

INTRO:

Goodmorning maam my name is angela shaine cruz

First I will get the blood pressure and the temperature of my patient.

“Sir may I have your arm to get your pulse rate?”

“yes”

“Also sir I will take your temperature is that ok?”

“yes”

“it was all normal”

ABDOMINAL SCRIPT:

”Are you experiencing abdominal pain?”

“Have you noticed a change in your appetite?”

“Have you experienced a change in bowel elimination patterns?”

“Do you drink alcohol? “

“do you exercise?”

What to inspect?

 Hands, Palm, nails


 Raise hand
 Arm side by side
 Neck
 Back
 Collar bone
 jaw

The patient should be lying flat with arms at his side and relaxed

 eyes
 mouth
 teeth
 tongue out
 Inspect the umbilicus
 Inspect the abdominal contour

“And now we will Measure the abdominal girth”


“it is ok to touch your stomach?”

Procedure:
Place the tape measure behind the client
Use the umbilicus as a starting point in measuring
Records the distance in designated units (inches/centimeters)

Assess abdominal symmetry

Position: Supine

“please raise your head to further assess whether it is a mass or hernia?

 Inspect abdominal movement when the client breathes


 Observe aortic pulsation
 Observe for peristaltic waves

What to auscultate?

 Bowel sounds
 Vascular sounds
 Friction rub over the liver & spleen

Procedure:

1. Listen over the R & L lower rib cage with the diaphragm of the stethoscope
2. Procedure: - Rest the stethoscope on a tender abdomen
3. Begin in the RLQ & proceed clockwise, covering all quadrants
4. Confirm bowel sounds in each quadrants
5. Listen for up to 5 minutes (minimum of 1 minute/quadrant) to confirm bowel sounds

Normal findings:

+ bowel sounds every 5-15 minutes

“the purpose of this is To evaluate the abdominal wall & intra abdominal content - To evaluate
abdominal mass structures”
2 ways:
1. Superficial palpation
2. Deep Palpation

Method:
2 hand method
- Begin at the RLQ and examine the entire abdomen gently by deep
Palpation
- Lay one hand over the abdomen and push with the second concentrating on the feel of
the bottom hand
- Once again, known tender area should be palpated last - If mass noted describe location, size, shape,
consistency, tenderness, pulsation and
mobility
-Press your finger gently and slowly and quick withdraw.
“do you feel pain?”
“If there is peritoneal inflammation withdrawal of pressure causes pain”

Liver Palpation
Method:
Place your R hand on the patient’s abdomen in the RLQ
- Gently move up to the RUQ lateral to the rectus muscle
- Gently pressing in and up, ask the patient to take a deep breath
Splenic Enlargement - To detect an enlarged spleen, percuss the lowest interspace in the L anterior
axillary line
- Ask the patient to make a deep breath and repeat. A change from tympany to dullness suggest
splenic enlargement

Method:
1. Have an assistant place her hand and forearm firmly at the midline
2. Place the palm of your hand at the L side of the abdomen
3. Sharply tap the R abdomen
4. Check for presence of “ fluid wave’

Test for Appendicitis


1. Assess for rebound tenderness & Rovsing’s sign
2. - Palpate deeply in the abdomen where the client has pain then suddenly release pressure
3. 2. Test for referred rebound tenderness
4. - Palpate deepley in the LLQ & quickly release pressure
5. 3. Assess for Psoas sign

Method:
 Raise the client’s R leg from the hip & place your hand in the lower thigh
 Ask the client to try to keep the legs elevated as you apply pressure downward
against the lower thigh
Assess for orburator sign
Method:
-Assess RUQ pain or tenderness which may signal inflammation of the bladder
- Press your fingertips under the liver boarder at the R costal margin & “ask the client to
inhale deeply”

Musculosckeletal assessment

“NOW, I will assess you in musculoskeletal”

ARMS
Step 1 : we need to inspect if there is any redness and swelling
Step 2 : then palpate the pose which is the radial artery and check the capillary refill by pressing down”
Step 3: press down the nail bed “
Step 5: range of motion of the fingers”
Step 6 : palpate the brachial artery which can be found in the band or arms “
Step 7: test the muscle strength by squeezing my fingers as she can”
Step 8: push up against my patient”
Step 9: push up against me.”
Step 10: ill be put my hand underneath the elbow and feel if there is the movement of the arm for
grading crepitus of the move of joints by laterally”

LEGS
Step 1: inspect the color of the legs any lesion, redness and swelling
Step 2 : look at the toe nails if it is health or have fungus
Step 3: palpate the knee to toe and feel her legs and push over her table
Step 4: palpate the feet and feel the pulses
Step 5: posterior tibial and dorsal sprit
Step 6: check the capillary refill at the two nails
Step 7 : let the patient push against me by toe
Step 8: check the Babinski reflex
Step 9: take up bowl of the foot and curved it
Step 10: look any toes that are curl which is negative response

Neurological assessment

Equipment:
- Cotton balls
-Safety pin
-Tongue depressor -Opthalmoscope
- Calipers
- Reflex hammer - Pencil & paper - Sweet & sour substance

Testing the ability to smell: test the olfactory


Procedure:
* Ask patient to sniff while placing a substance beneath the nostril
* Examiner hold the other nostril closed
testing the ability of sight
*cover the other eye and follow my finger vise versa ang tell how many finger it is
* stare the object and follow it with he two eyes up/far and near

Facial nerve
*open the mount
*frown look
*Smile
*top out cheeks

Testing Sensation of Light Touch


Procedure:
- Examiners apply a wisp of cotton just firmly enough to stimulate the sensory nerve
Ending

Frown, smile, close eyes tightly, puffed cheeks.

Eyes - papasundan ko ng mata yung penlight, hindi nakasindi

Nose -magpapaamoy ako (both, tapos tatakpan yung isang nostrils)

Mouth -papatikim Touch - bulka na basa

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