Mid-Term Shift Assessment

Question 1

Subjective

Answer 1

Denies cough. 
Denies pain. 
Reports last BM yesterday, solid and brown. 
Reports last void one hour ago, yellow. 
No difficulty with urination or BM.

Question 2

VS

Answer 2

Radial HR regular, rate 64 bpm, 2+, strong non-bounding. RR 14/min, regular, unlabored, silent.
BP______.
Temp______.

Question 3

Skin/Integumentary

Answer 3

Skin warm, dry, and intact; without lesions, wounds, bruises throughout the body bilaterally.

Skin consistent with ethnic background throughout the body bilaterally.

No tenting throughout the body bilaterally.

Question 4

Neuro

Answer 4

A&O x3, oriented to time, place, and person.

Speech clear, evenly paced.

Pupils equal, round, reactive to light, and accommodation.

Question 5

EENT

Answer 5

Eyes: sclera white, no discharge
Ears: no lesions, wounds, bruises, no drainage
Nares: patent, no discharge

Throat: oral mucosa moist, pink, no lesions. Tonsils present.

Question 6

Neck

Answer 6

No lesions, no bruises, no wounds.
No LAD.
Trachea is midline.
Full ROM.

Question 7

Cardiovascular

Answer 7

Regular rate and rhythm.

S1 and S2 noted.

No murmurs or extra sounds.

Peripheral pulses present, 2+ all extremities & equal bilaterally.

Cap refill <2 seconds.

Question 8

Respiratory

Answer 8

Clear to auscultation bilaterally.

No adventitious breath sounds.

Question 9

Musculoskeletal

Answer 9

No deformities, no limitations in all extremities.
Full ROM.
Gait steady, evenly spaced with opposite arm swing.

Question 10

What are questions you need to remember to ask and what is most important when looking at skin.

Answer 10

Do you have any pain?
Do you have a cough?
When was your last BM (consistency, color, smell)?
When was the last time you urinated (color, smell)?

**remember after cardiovascular to assess legs for bruising, wounds, lesions, edema; turgor; tibial pulses; cap refill on toes.