Question

Please type the answer correctly :)

7 weeks patient, diagnosed with bronchiolitis

how to document these normal finding/how to assess

Head and neck: (size, shape, symmetry, fontanels, head control, head circumference if less than 2 yrs.,teeth, nose, eyes ears)

Respiratory: (breath sounds, retractions, nasal flaring, shortness breath, supplemental O2, shape thorax)

Cardiovascular: (quality, rate, murmur, cyanosis, mottling, edema, peripheral pulses, capillary refill)

Gastrointestinal: (appetite, how diet is tolerated, contour of abdomen, bowel sounds, bowel movements, nausea, emesis, NG tube)

Musculoskeletal: (activity, weakness, gait, deformity, fractures, traction, cast, spinal curve and mobility, mobility of joints)

Answer 1

Assessment:

General health status: Assess the overall physical and emotional condition of the patient. Look well, or ill, pale, active or lethargic, Posture, anxiety, agitation, or depressed, dull.

Vital signs: Record the patient's temperature, pulse, respiration, blood pressure, oxygen saturation, pain assessment.

Head and neck:

• Assess the shape and symmetry of the head.
• Assess the fontanels.
• Observe the eyes symmetry, pupil reaction to light, eye movements.
• Assess for symmetry of nose, any deviation.
• Assess for symmetry of lips, color, crackles, or inflammation.
• Observe for teeth alignment and for any dentures, dental caries, gingivitis.
• Observe the tongue and uvula for tonsilitis.
• Assess the symmetry of the neck and shape.
• Palpate the thyroid gland for any swelling.

Respiratory system:

• Assess for signs and symptoms of dyspnea, cough, and its onset, frequency, and duration.
• Assess for the chest symmetry and shape( both sides are similar).
• Assess for the type of breathing- normal, deep or shallow.
• Assess for the use of accessory muscles for breathing.
• Auscultate for normal breath sounds and presence of any wheezing, stridor, or crackles.

Cardiovascular System:

• Assess the nail buds and tongue for any cyanosis.
• Assess the circulatory status and findings of any pink, flushed skin.
• Assess the hydration status and check for any edema in the lower extremities.
• Assess for any dilated jugular venous pressure.
• Palpate the peripheral pulses in the upper and lower extremities.
• Ascultate the apical pulse and presence of s1 and s2 sound.
• Auscultate carefully for any murmurs.

Gastrointestinal system:

• Assess patient tolerance for food.
• Assess for any abdominal pain, location, type, frequency, and duration.
• Assess for the signs and symptoms of nausea, vomiting, diarrhea, constipation.
• Asess urinary color, frequency, and urgency,.
• Assess the bowel elimination pattern.
• Assess the shape and symmetry of the abdomen. e.g round, flat.
• Assess for abdominal distension.
• Assess the umbilicus for any redness or dryness.
• Palpate for any abdominal pain or tenderness.
• Measure the abdominal girth level.
• Auscultate for the presence of normal bowel sounds.

Musculoskeletal system:

• Assess for body posture and symmetry.
• Assess gait and weakness.
• Assess for the deformities of extremities
• Observe for any fractures, injuries.
• Observe for the spinal alignment and tenderness.
• assess the range of motions in joints.
• Assess for the strength and limitation of muscle movement.
• Palpate for pain and stiffness of muscles.

Documentation:

Head and neck: head and neck symmetry, Proper vision, the presence of nasal flaring. no hearing aid, no swelling in the neck.

Respiratory: Tachypnea, breath sounds show wheezing. lung retractions found.

Cardiovascular: No chest pain and palpitations, no murmurs, normal apical sounds.

Gastrointestinal: Normal urinary and bowel pattern. Tolerant of food. No pain or tenderness.

Musculoskeletal: No joint tenderness or swelling. No changes in muscle strength.