RADIOLOGIC TECHNOLOGY PROGRAM
MONTGOMERY COLLEGE
GUIDE TO PERFORMING A “GENERAL”
PATIENT ASSESSMENT
What is this cat feeling?
Name_____________________________________
DUE DATE: March 9, 2010
TIME OUT ASSIGNMENT (SEE PAGE 12) DUE DATE: TIME OUT
LAB DATE
Montgomery College
Radiologic Technology Program
RT 102
Patient Care Assessment
Purpose: To support patient care objectives first reviewed in RT 119
Outcome: improved patient care methodologies when performing radiographic
procedures
Directions:
Students are to complete this patient care booklet by answering questions as they
relate to patient care objectives. Students should refer to the Patient Care in
Radiography book by Ehrlich and can also use reputable sources via the internet
and/or other textbooks. The student’s written responses to the questions must be
typed and placed within this booklet either on the next page identifying the
question they are answering or on the same page. Students are encouraged to
critically think as to how they would handle the scenarios and questions in the
booklet. This means that if a student is confident they have a good solution to the
question and do not feel they need to refer to the book, the student is encouraged
to provide this answer. The instructors are looking for thoughtful thorough analysis
of the questions and assessment of scenarios.
The booklet is to be completed and handed in on March 9, 2011. Upon review, if
answers are considered incomplete, the student will be asked to review those
answers and resubmit the booklet by April 27, 2011. Successful completion of the
booklet will result in a grade of 100%.
The Time Out Lab, which is mandatory, requires the student to complete a small
assignment prior to the lab and the student must bring this assignment for
evaluation to their Time Out Lab as this is part of the lab schedule .This assignment
can be found on page 12 of this handout and is a SEPARATE assignment from the
booklet. This assignment must also be typed. Failure to bring this assignment in
will result in a zero for the lab day.
Students are reminded that this is an individual project and therefore the answers
should be recorded in each student’s own words.
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Guide to Performing a “General” Patient Inspection
(Initial Patient Assessment)
Gather patient information before entering room:
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Information from patient requisition, chart and or a prescription
 Admitting diagnosis
 Past Medical History (PMH)
 Past Surgical History (PSH)
Medications that patient has taken or been given
Communicate with clinical instructor if you have any questions or
concerns
WHY SCENARIO
A radiographic examination of the pelvis and right hip is ordered
on an outpatient male is ambulatory but uses a cane with
assistance. The only information on the requisition was the
patient came in after a fall.
In terms of obtaining the best radiograph why is it important to
obtain the patient’s past medical history, past surgical history and
any medications he may be using. Speculate on what adjustments
you would make if the patient indicates prior pelvic issues.
Review Chapter 3 in Patient Care in
Radiography
Answer Critical thinking exercises 1-5 on
page 97
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Upon entering the room with the patient:
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Wash hands immediately before entering patient room and put gloves
on
Introduce yourself and check patient’s identification bracelet
Explain to the patient what you will be doing throughout the exam
Remember to always provide privacy
Obtain Patient’s History or Reason for Exam :
1. What is wrong?
2. What are patient’s symptoms?
2. Duration
3. What makes it better?
4. What makes it worse?
5. LMP, if female
When you are ready to leave the room for the first time be sure to
thank your patient for allowing you to participate in their health care
WHY SCENARIO
Why is it important to make an assessment of the room you will be taking the
portable in? What sorts of observations once you enter the room will give you
information as to how to best obtain the radiograph without compromising
patient safety?
Review Chapter 6 in Patient Care in
Radiography
Answer Critical thinking exercises 1-3 on
page 221
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Before leaving the patient alone in the room:

Scan room before leaving:
 make sure patient is safe and has everything he/she needs
within reach: call light, phone, etc.
 make sure bed is in lowest position & side rails are up
 WASH YOUR HANDS
Communication:
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Use appropriate patient communication techniques
During your “Patient Interview” identify patient concerns and goals, &
chief complaint, ask yourself: What should I focus on when
providing care to this patient?
Communicate to your patient the desire to help in any way possible
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QUESTIONS
Hint: The General Inspection (Assessment) begins the moment the
technologist enters the room with the patient.
Be observant:
1. Physical Appearance & Hygiene
What information can you gather about the patient by observing the patient?
Be specific about the physical appearance, vital signs, other observable physiological
conditions.
2. Body Structure and Position
What information can you gather about the patient regarding habitus and posture/position.
What information does the patient’s body’s posture or position give you in terms of pain,
mobility etc?
3. Body Movement
How can you assess this?
How do involuntary movements inform you as a radiographer and how would you
accommodate this issue and still obtain a radiographic image.
What does “guarding an extremity or a movement” mean and what impact does that have
when positioning a patient?
What clues will you tell if a patient is in pain when moving or lying still
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4. Behavior, Emotional & Mental Status
WHY SCENARIO
A radiographer, after assessing the patient has indicated that the patient seems a bit
confused and does not seem to want to answer questions. What non-verbal cues from the
patient may have provoked this assessment?
.
What assessments can a radiographer make to assess behavior, emotional and mental
status and why is this important? How would you adjust your patient care strategies to
accommodate a patient demonstrating behavior, emotional or mental challenges?
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NEUROLOGICAL SYSTEM
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LOC (level of conscious)
Orientation
Ability to follow commands
Speech
Hearing
Vision
Sensory aids
INTEGUMENTARY SYSTEM
 SKIN for:
 Lesions, rashes
 Color, temperature
 Texture,moisture,turgor
 Bruises,Wounds, Incisions
 Drains (type, location,
Drainage)
 Dressings (drainage)
GASTROINTESTINAL SYSTEM
RESPIRATORY SYSTEM
 Respirations for:
Rate, Rhythm, Depth, Symmetry
 Pulse Ox.
 Skin Color
 SOB (Shortness Of Breath)
 Breath Sounds
 Cough (dry or productive),
strong or weak
 Sputum (color)
 Oxygen: O2 / Room Air
Nausea, vomiting
Oral mucosa
Abdominal pain, distention
Last BM (any changes), bowel habits, pain
or difficulty with defecation
 Diarrhea, Constipation
 Bowel Sounds (normal, hyperactive,
hypoactive)
Presently taking stool softners or fiber
supplements
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GENITOURINARY SYSTEM
(Reproductive System)
 Urinary Pattern (frequency, urgency,
hesitancy, incontinence, change in urine
stream)
 Painful urination (dysuria)
 Flank pain, pain, lesions
 Blood in urine (hematuria)
 Urine characteristics: color, clear, odor,
sediment, clots
Discharge Females:
 LMP, abnormal menstrual cycle
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Refer and read the article-(see page 10) A Patient Centered Care Model.
ASSINGMENT: Assessment of the patient is not noted on this model. Add
circles from the patient circle to include information that assessment of the
patient would provide.
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TIME OUT LAB
Outcome: using a simulated environment, students in groups of four will have an
opportunity to participate in a portable study. Students will then debrief and share
assessment of their performance, emphasizing the patient care component of the
simulated examination.
Students will sign up for one of the following Friday Labs
Time 9:30-12:30
February 4
February 25
April 1
April 29
May 6
Students MUST bring to the lab the attached TIME OUT Assignment as prior to
the simulated lab, the assignment will be reviewed and discussed. Failure to
complete this assignment will result in a zero for the lab grade. Assignments must
be typed the answers do not need to be submitted in complete sentences.
TIME OUT LAB schedule
9:30-9:40
Review homework assignment.
9:40-10:30
Live scenario participation
10:30-11:30
Sim Man Scenario (HC 341)
11:30-12:30
Debrief
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RADIOLOGIC TECHNOLOGY PROGRAM
MONTGOMERY COLLEGE
TAKOMA PARK/SILVER SPRING CAMPUS
RT 102 TIME OUT ASSESSMENT (information based on Chapter 6, Erlich)
DUE ON THE DAY OF THE TIME OUT LAB
1. What are some signs to look for that may indicate that a patient is in respiratory
distress?
2. How do various respiratory or cardiac conditions affect your technique? Also,
what methods may be used in obtaining an adequate chest, abdomen radiograph
without motion?
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3. Review in your patient care book any methods that help you obtain a blood
pressure reading. Indicate the range for a normal blood pressure.
4. What is a normal respiration range for an adult and how do we obtain a
respiration count?
5. What information does a cardiac monitor provide to us? It is important for the
radiologic technologist to recognize a few of the configurations that may be life
threatening situations? What does a normal ECG waveform resemble? Explain the
various parts of the graph. Explain what happens during bradycardia, tachycardia
and PVC’s and explain how the patient may feel.
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6. What are pleural vac(chest tubes) used for, why must we be careful around
them? What can happen with the tubing and the box during a portable exam?
7. If patient is diabetic and complains of being weak or is hungry and asks for food
and has taken their insulin, what should your response be?
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