NURSING 1I02 Study Guide - Midterm Guide: Facial Symmetry, Prescription Drug, Presenting Problem
15 May 2018
School
Department
Course
Professor
N1I02-Clinical Skills Review Checklist
Interview:
*Hand Sanitizer*
“Hello, my name is ________”
“I am a Level 1 Nursing Student at McMaster”
“Today I am here to do ___________”
-dont ask ‘What brings you in here today?’
“It will take approximately _____minutes, does that sound good with you”
“Could I get your full name please? And what name would you like me to call you by (WRITE
NAME DOWN)”
“Just adding,all information from today will be kept confidential and just shared with the health
care team.”
-> “This is my examination so I will be verbalizing all my findings to the examiner, today I will be
conducting_________, is that alright with you?”
“Before we begin, are you comfortable how you’re seated right now?”
-Move bed to same height as you
General Survey:
*say findings out loud*
● Appearance
○ What is the client’s gender?
○ Does the client appear their age/ demonstrate physical characteristics of their
age?
○ Are there any obvious signs/symptoms of distress? (indicate pain, difficulty
breathing, anxiety)
○ What is their LOC? (conscious, aware of surroundings, responsive)
○ What is their skin colour (even tone, no redness, jaundice, sweaty, no rashes,
marks)
○ Is there facial symmetry? Distinguishing features? Physical irregularity?
○ Does the client appear to have adequate levels of hygiene/grooming? (hair,
skin,nails, body odor, oral hygiene)
○ Is their dress appropriate for weather conditions, lifestyle and age? (setting,
weather, age)
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● Body Structure
○ Appear thin, lean, muscular, slightly overweight, obese, overdeveloped,
underdeveloped?
○ Does their body structure reflect their age, lifestyle and level of health?
○ Is their body symmetrical?
○ How is the client’s posture/body position? (erect, relaxed, upright, poor slouched)
○ Do they appear properly nourished?
○ Are there obvious signs of physical deformities and/or abuse?
● Behaviour
○ What is the person’s current affect/facial expressions? (happy, sad, irritable,
anxious, angry, neutral, appropriate to situation)
○ What is the patient’s reported overall mood? (depressed, lethargic, content,
stressed, body language)
○ Do their verbal expressions match their nonverbal behaviour?
○ Is the client’s mood appropriate for the situation?
○ What is the client’s manner? (friendly, cooperative, suspicious, hostile)
○ Are they alert and orientated? Able to keep eye-contact and appropriate
expressions?
○ Is the speech understandable and moderately paced? Is it associated with their
thoughts? (rate, rhythm, amount, articulation, volume, spontaneity, effortless,
aphasia)
● Mobility & Gait-> “Could you just walk to the door and back for me?”
○ Are movements purposeful and smooth? (note any tremors)
○ Is their gait coordinated and well-balanced? (voluntary, coordinated, smooth)
○ Are there signs of immobility or decreased range of motion?
○ Are they able to sit comfortably and stand erect?
Health History:
*make note of source of history; LOC; reliability at the time*
● Biographical Data
● Name
● Address
● Phone number
● Birthdate
● Birthplace
● Gender (at birth)
● Marital Status
● People in Household
● Ethnicity
● Cultural Background
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find more resources at oneclass.com
● Occupation
● Primary Language Spoken (at home too)
● Height,Weight
● Pregnant/Children
● Reason(s) for seeking care
● Chief complaint (signs,symptoms, OPQRSTU)
● (i.e. I have not had a full assessment in 10 years.)
● Current health/History of present illness
● How do you feel overall? (fatigue, weakness, hot flashes, chills, muscle pains)
● Any recent changes to your overall health status? (weight, gain,loss)
● Current medications (prescription, over the counter)
● Current illnesses/medical conditions/Allergies (ex. diabetes , hypertension,
anemia, vitamin deficiencies,high cholesterol)
● Medications: dosage,frequency, reason
● Vitamins, supplements
● Past medical history
● Past/childhood illnesses
● Chronic conditions
● Accidents/Injuries
● Hospitalizations, Surgeries
● Allergies
● Immunizations
● Seen other specialists before
● Past prescribed medications & over counter
● Family history
-Make rough genogram-
● If say yes, ask who (maternal/paternal), 2 generations up
● History of chronic illnesses (hypertension, high blood pressure, cancer, diabetes,
strokes, blood disorders, sickle cell anemia, arthritis, obesity, alcoholism, mental
health, seizures, kidney disorders)
● Review of systems
● Skin,Hair,Nails
(eczema, psoriasis, brittle nails, dry scalp, hives, rashes, excessive dryness,moisture,
change in colour, texture, bruising, burns)
● Head
(headaches, migraines, dizziness, head injuries, history of concussions)
● Eyes
(decreased vision, blurring, blind-spots, diplopia, redness, watering discharge,
glaucoma, past optometrist check up)
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
I am a level 1 nursing student at mcmaster . Dont ask what brings you in here today?". It will take approximately _____minutes, does that sound good with you . And what name would you like me to call you by (write. Just adding,all information from today will be kept confidential and just shared with the health care team. > this is my examination so i will be verbalizing all my findings to the examiner, today i will be conducting_________, is that alright with you? . Before we begin, are you comfortable how you"re seated right now? . Are there any obvious signs/symptoms of distress? (indicate pain, difficulty breathing, anxiety) What is their loc? (conscious, aware of surroundings, responsive) What is their skin colour (even tone, no redness, jaundice, sweaty, no rashes, marks) Does the client appear to have adequate levels of hygiene/grooming? (hair, skin,nails, body odor, oral hygiene)
