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Urine output
sediment
colour
bloody urine
quantity
O2 saturation
respiratory rates
temperature
blood pressure
Vital Signs
dressing
toileting
bathing
Measurements
Waist to hip ratio
Arm span
BMI
height
weight
Behaviour
personal hygiene
dress
speech
mood
facial expression
Mobility
range of motion
gait
walking
Body structure
symmetry
stature
Physical appearance
facial expressions
skin colour
sexual development
Level of conscieness
age
Symtoms
not observable to others
perceived or experienced by the patient
sensation or emotion
How it feels
signs
Obseved by others
What you see
recognize boundary violations
keeping secrets with clients
spending extra time with clients
having special clients
client’s best interest
to act purposefully
recognize own experience is shaped by several factors
beliefs
accomplishments
Early childhood experience
education
gender
socio economic conditions
Health
Culture
Nationality
Race
conflict
should and should not do
feces
body odour
urine
Alcohol
direct
indirect
percussion notes
density
size
location
fingertips to produce a vibration
duration
quality
loudness
frequency
stethoscope
normal sounds vs abnormal
concentration and practice
Tender areas are palpated last
should be warm
fingernails should be short
compare to opposite side
cheif complaint
day of addmission
prior hospitalizations
injuries
surgeries
allergies