NURS 3108 Lab Manual 1 NURS 3108: Health Assessment and Application Lab Manual Spring 2024 NURS 3108 Lab Manual 2 Tips for using the lab manual: All students need to identify a lab partner with whom to practice these health assessment skills. Tips for using the lab manual: 1. All students need to identify a volunteer with whom to practice these health assessment skills. It is best if you use the same lab partner throughout the course. 2. Remember that all information shared and documented with your lab partner is confidential and should only be shared with course faculty as part of grading & evaluation. Breach of this confidentiality is a breach of the honor code of the university and nursing practice and may result in dismissal from the course. a. If you or your lab partner are not comfortable sharing personal information requested during the practice health history, you are not required to divulge it. 3. Remember to follow instructions for documentation. This includes: a. Use of BLACK ink or you may download this document and complete it electronically. b. When you make an error, draw a single line through the word(s) and write “error”, the date, and your initials next to it. c. Remember that abbreviations are approved by individual institutions and when you are in a clinical setting or practice, you must adhere to the abbreviations of that institution. d. When writing a note, include subjective information first, followed by objective. 4. It is very important to take practice of the interview and exam seriously. You will need to ask patients these questions in the clinical setting and must be comfortable with the content. It is important to use the medical terminology but to also be able to ask questions in a way that patients will be able to understand, so practice asking your partner(s) questions in a manner that a layperson will understand. 5. These guidelines include extensive detail; however, they are not all inclusive. This detail is included to assist in the teaching-learning process and is not intended to imply that it will be used in totality in any clinical situation. Take note that there are suggestions of various possible findings listed in the lab manual, but they are not all inclusive and do not include all the potential findings, just some suggestions of frequently seen issues. 6. Within the lab manual, you may notice some sections in italics with the label “Special Circumstances”. This indicates “Special Circumstances” and includes skills that are often used in advanced practice or specialty areas for certain types of patients. While you should be aware of these skills for the purposes of the course exams in class and in case you encounter some of the problems, you will not be held responsible for them during performance exams. 7. Please dress comfortably for practice for lab so that your partner may practice his/her skills as appropriately as possible. For the chest and lungs and heart/blood vessels, please note that your partner will need to be able to inspect and listen with the stethoscope on your chest wall, so please dress appropriately. Privacy is of utmost importance, and gowns and drapes can be easily used to ensure your privacy and comfort. 8. It is very important to take practice of the interview and exam seriously. You will need to ask patients these questions in the clinical setting and must be comfortable with NURS 3108 Lab Manual 3 the content. It is important to use the medical terminology but to also be able to ask questions in a way that patients will be able to understand, so practice asking your partner(s) questions in a manner that a layperson will understand. 9. These guidelines include extensive detail; however, they are not all inclusive. This detail is included to assist in the teaching-learning process and is not intended to imply that it will be used in totality in any clinical situation. Take note that there are suggestions of various possible findings listed in the lab manual, but they are not all inclusive and do not include all the potential findings, just some suggestions of frequently seen issues. Grading Criteria for Weekly Lab Worksheets NOTE: Checklists included in this manual are to be used as a guide only, please complete a narrative note for each weekly assignment. Lab Manual is worth 10 points. Points will be giver for your work being turned in by due date as specified by individual clinical instructor, correct spelling and use of medical terminology, accurate description of health assessment findings related to partner, and for your narrative note being system specific and comprehensive. WORKSHEET 1 LAB PARTNER’S INITIALS: ___________ Past Medical History: Allergies, Reaction & Treatments _____NKDA Latex Allergies: _____ Medications: __________________________________ Foods: _______________________________________ Environmental/Contact Agents: _____________________ Seasonal: _______________________________________ Tape: __________________________________________ X-Ray Dye: _____________________________________ Transfusion Reaction: _____________________________ General State of Health: _____Good _____Fair _____Poor Recent changes in health? _____No _____Yes If yes, identify: _____________________________________________________________________________ Hospitalizations/Surgeries: (Inpatient & Outpatient) _____None Dates Accidents/Injuries: Reason _____None Full Recovery () SEQUELAE Complications (Explain) NURS 3108 Lab Manual Dates Type 4 Cause Treatment/s Full Recovery () Complications (Explain) Family History: Typical Day Time up ___________________ Time to Bed ________________ Activities of Daily Living (ADL) _____________________________________________________________________________________________ _________________________________ Are you able to perform all of your ADL’s _____No Do you need any assistance with Daily Care _____No _____Yes _____Yes Sleep/Rest: Hours/Night __________ Feel Rested _____No _____Yes Recent Changes in sleep pattern _____No _____Yes Sleep Aids/Measures used _____No _____Yes (If yes, identify: ________________________ ____________________________________________________________________________ Daytime naps _____No _____Yes Difficulty Falling Asleep _____No _____Yes Difficulty Staying Asleep _____No _____Yes Exercise/Leisure: _____None Type _________________________________ Amount/Frequency _________________________________ Do you enjoy your exercise/leisure activities _____No _____Yes Recent changes in exercise or leisure activities _____No _____Yes Religious/Cultural Practices: Do you have any religious or cultural practices or beliefs related to diet, pain management or health care treatments? _____No _____Yes If yes, explain: Tobacco/Alcohol/Drugs: (Include current & past use. If no longer using, give date quit & method used to quit.) NURS 3108 Lab Manual 5 Tobacco: _____No _____Yes Type: _____Cigarettes How long used? ___ Amt/Day ______ _____Cigars How long used? ______ Amt/Day ______ _____Pipe How long used? ______ Amt/Day ______ _____Snuff How long used? ______ Amt/Day ______ _____Chewing Tobacco How long used? ______ Amt/Day ______ If quit using tobacco: Type, Length of time & Amt Used____________________________________ When & How Quit _______________________________________________ Alcohol: _____No _____Yes Type (Beer, Wine, and Liquor): __________________________________________ How old were you when you first started drinking? _______________________ How long have you been drinking? ____________________________________ Amount/Frequency/Day: ____________________________________________ If quit using alcohol: Type, Length of time & Amt Used _______________________________ When & How Quit _________________________________________________ Recreational Drugs: _____No _____Yes Outlook on life: How do you view your life situation now? ______________________________________________________________________________ What do you see as your personal strengths? ______________________________________________________________________________ What are your concerns? Describe at least 3 verbal and 3 nonverbal communication techniques used when interacting with your partner today? 1.__________________________________________________________________________ 2.__________________________________________________________________________ 3.___________________________________________________________________________ Which additional types of communication techniques would have been beneficial with your client? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ NURS 3108 Lab Manual 6 Nutrition Analysis Complete a dietary recall of breakfast. Analyze the adequacy of the diet based on the food pyramid. Use the format in the previous example. Food & Serving Size Amount (Include time of day eaten) Food Group & # Servings Breakfast Only: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Analysis Suggested Food Group Servings/Day breakfast Breads, cereals, rice, pasta 6-11 Vegetables 3-5 Fruit 2-4 Milk, cheese, yogurt 2-3 Meat, poultry, fish, beans, eggs 2-3 Fats, oils, sweets Use sparingly Miscellaneous Caffeine Use sparingly Sodium Use sparingly Alcohol Use sparingly Water 8 cups Actual Servings/Day Food Preferences: Food Aversions: Food Allergies: Appetite: GENERAL Inspect General Appearance for: (Explain all unexpected findings) Overall appearance: Overall development: Overall nourishment: Personal hygiene: Analysis # Excesses, # Deficits noted for NURS 3108 Lab Manual Level of distress: Cooperative Vital signs: T__________ P__________ R__________ BP_________ O2 Sat_________ Weight (current)__________ Usual weight___________ BMI __________________ Height___________ Last Menstrual Period (LMP) ___________________ MENTAL STATUS Observe Appearance & Behavior: (Appropriate to situation) Affect: Emotional Status/Mood: Eye Contact: Body Movements: Grooming/Dress: Assess Mental Status for: Judgment: Memory - ST & LT: Orientation - A & O x 4 -Time, place, person & situation: Pain Assessment: Have you had pain in the recent past? ___No ___Yes_________ Do you currently have pain? ___No ___Yes________________ Pain Intensity Scale: (# 0-10) _________________ Location: _________________________________ Radiation to: ______________________________ Is the pain: _____Burning _____Dull _____Pressure _____Heavy _____Sharp _____Cramping _____Other _______________________ Does pain affect any part of your daily life? _____No _____Yes Does pain affect your: _____Sleep _____Appetite _____Physical activities _____Relationships _____Emotions _____Concentration Duration: _____Constant _____Intermittent How long have you been in pain? ______________________ What relieves your pain? _____Rest _____Heat _____Cold _____Medication _______________ _____Other _________ What aggravates your pain? ______________________________ Present Pain Management: ______________________________ 7 NURS 3108 Lab Manual 8 Assessment of Patient in Pain: Respiratory Rate_______ Pulse Rate_______ Affect_________________________________ WORKSHEET 2 Focused assessment related to skin, hair, and nails SKIN: Inspect & Palpate Skin for: (Explain all unexpected findings including location, size, description. Descriptors provided are not the only possibilities, simply suggestions) Color: ___________ Lesions/Masses Edema Erythema Red Streaks (Lymphangitis) Vascularity Integrity Symmetry Odor Hygiene _____________________ Moisture Mobility Temperature Tenderness Texture Turgor – clavicles Thickness Other: ______ Scars HAIR & SCALP: Inspect & Palpate Scalp for: Color: ________________ Lesions Scaliness NURS 3108 Lab Manual Mobility Tenderness Thickness Inspect & Palpate Hair for: Quantity Distribution Texture Foreign bodies Cleanliness/Hygiene Color: __________ Nails Inspect & Palpate Nails for: Shape _____________ Symmetry Lesions Texture Thickness Other(describe): __________________ Color: _________ Cyanosis Capillary refill Clubbing bbing: _______________ Cleanliness/Hygiene Nail Base Adherence to Nail Bed Firmness Ridging Irregularities 9 NURS 3108 Lab Manual 10 What are the most common abnormal findings in the adult with skin, hair, and nails? What differences might you see with the older adult? Include citation. Describe your strengths and weakness you have identified. Describe how you will continue to enhance your strengths and improve weaknesses. NURSING NOTE REGARDING YOUR ASSESSMENT: WORKSHEET 3 Assignment: Focused assessment related heart and peripheral vascular system HEART, BLOOD VESSELS & HEMATOLOGIC: (EXPLAIN ALL UNEXPECTED FINDINGS INCLUDING LOCATION, SIZE, DESCRIPTION. DESCRIPTORS PROVIDED NOT THE ONLY POSSIBILITIES, SIMPLY SUGGESTIONS) ASSESS GENERAL APPEARANCE FOR: SIGNS OF DISTRESS NONE MILD MODERATE SEVERE SKIN COLOR COLOR ___________ CYANOSIS PALLOR Capillary refill Clubbing JAUNDICE Inspect the Precordium (supine) (palpate if pulsations or murmur): Pulsations Lifts, heaves, thrills Apical impulse (PMI) Auscultate the carotid pulses (with bell) for: Rhythm, Strength, Symmetry, Bruits NURS 3108 Lab Manual 11 Auscultate the heart for: Rate, rhythm & intensity Auscultate the cardiac valve areas with the diaphragm & bell, sitting, supine, and left lateral when applicable. (“APE To Man”) S1 – systole - closure of tricuspid & mitral valves – loudest at apex S2 – diastole - closure of aortic & pulmonic valves – loudest at base Aortic – 2nd ICS – RSB Pulmonic – 2nd ICS – LSB Erb’s Point – 3rd ICS – LSB Tricuspid – 4th ICS – LLSB Mitral – 5th ICS – LMCL Auscultate the cardiac valves for other heart sounds Murmurs/Rubs/Gallops Splits S3&S4 S4 PERIPHERAL VASCULAR: Inspect & palpate the nails for: Clubbing, color, & capillary refill Inspect the jugular neck veins for Pulsations JVD Inspect & palpate lower extremities for: Dependent edema Inspect skin for Varicosities Venous stars Distal sensation ct Tenderness Temperature Color______________ Cyanosis Hair distribution appropriate Skin changes None NURS 3108 Lab Manual 12 Ulcerations None Texture smooth Describe unexpected findings: _____________________________________________________ ______________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Palpate peripheral pulses for rhythm, strength & symmetry: Indicate strength (0, 1+, 2+, 3+, 4+) & B, L or R.) Please complete for all Brachial Radial Popliteal Posterior Tibialis Dorsalis Pedis Assess lower extremities for signs of DVT: Pain None Swelling None Erythema None Decreased Pulses All palpable Vital signs: T__________ P__________ R__________ BP_________ O2 Sat______________ How does your Partner tolerate activity? ______________________________________________________________________________________ NURSING NOTE REGARDING YOUR ASSESSMENT: NURS 3108 Lab Manual 13 WORKSHEET 4 Assignment: Focused assessment related lung and respiratory CHEST & LUNGS: (Explain all unexpected findings including location, size, description. Descriptors provided are not the only possibilities, simply suggestions) Assess General Appearance: Relaxed Facial expressions appropriate Trachea midline Brisk capillary refill Nasal flaring Intercostal retractions Clubbing Accessory muscle use Cyanosis Pallor Pursed lip breathing. Coughing None productive: _______ non-productive Inspect the chest at rest and during inspiration & expiration for: Movement & expansion Symmetrical Asymmetrical Chest wall shape/size Symmetrical Asymmetrical Pulsations, bulges, depressions, lesions, masses, scars, crepitus, retractions None Other: __________________ Inspect the size & shape of the chest wall: AP Diameter 1:2 1:1 (barrel chest) Chest Wall Abnormalities: None Pectus Carinatum (pigeon) Pectus Excavatum (funnel) Kyphosis Scoliosis Assess the breathing pattern for: Rate: _________ Bradypnea Tachypnea Depth Regular Hyperpnea Shallow Rhythm Regular Irregular Biot’s Cheyne-Stokes Ease/effort Easy Labored: ________________ Audible sounds None Present: _________________ Palpate the chest wall if c/o pain or tenderness: Note location of tenderness, pulsations, bulges/depressions, lesions or masses, crepitus, stability of ribs: ___________________ Auscultate posterior, anterior & lateral lung fields for: Air exchange in all fields Present Not present: _________ Bronchial sounds Present Not present: _________ Bronchovesicular sounds Present Not present: _________ Vesicular sounds Present Not present: _________ NURS 3108 Lab Manual 14 Auscultate for diminished or adventitious lung sounds (if present, describe location, upon inhalation/exhalation): No diminished lung sounds No adventitious lung sounds Lung Sounds Diminished: ________________________ Crackles (Rales): ________________________________ Wheezes: _____________________________________ Rhonchi: ______________________________________ Rubs: _________________________________________ Vital signs: T__________ P__________ R__________ BP_________ 02 Sat____________ What tests are associated with the Respiratory system? Include citation. _____________________________________________________________________________________________ _____________________________________________________________________________________________ Has your client had any test associated with the respiratory system? if so, identify the test(s) and result(s): If not, what are some? Include citation. _____________________________________________________________________________________________ _____________________________________________________________________________________________ Describe how your communication skills have improved? Please be specific. NURSING NOTE REGARDING YOUR ASSESSMENT WORKSHEET 5 ABDOMEN: Inspect the abdomen for: Shape/Contour NURS 3108 Lab Manual 15 Flat Rounded scaphoid Distension/Bulges, Hernias None Present: _____________ Masses/Lesions/Scars None Present: _____________ Symmetry Symmetrical Assymetrical: ______________ Pulsations None Present: ________________________ Peristalsis Not visible Visible: _____________________ Inspect the umbilicus for: Location Midline Other: ________________ Contour Inverted Everted Other: _______________ Lesions None Piercing Other:_________________ Auscultate for bowel sounds: (with diaphragm, lightly) All 4 quadrants Present Absent: _________________ Frequency 5-35/min Hypoactive Hyperactive Other: __________________ Last BM__________________ Diet: _________________________ Continent? Yes/No GU: Last voiding? ____________ Color? ___________________ Amount? ________________ Continent: Yes/No Auscultate for bruits: Aorta None audible Audible: ______________ Renal None audible Audible: ______________ Iliac None audible Audible: ______________ Palpate the abdomen lightly in all 4 quadrants: (knees flexed & 1st ask if any areas tender) Soft Firm No distention Distention Nontender Tender (location & rating): ______________ No Guarding Guarding (location): _________________ No masses Masses palpated (location, size, describe): _________ Vital signs: T__________ O2 Sat_____________ P__________ R__________ BP_________ What are a few tests commonly associated with the GI system? (Include Citation) ______________________________________________________________________________ NURS 3108 Lab Manual 16 _____________________________________________________________________________ NURSING NOTE REGARDING YOUR ASSESSMENT WORKSHEET 6 MUSCULOSKELETAL: Inspect the skeleton, extremities, muscles & joints for: Symmetry Symmetrical Asymmetrical: __________ Alignment/Contour Appropriate Other: _________________ Size Appropriate Other: ________________ Deformities None Other: _______________________ Muscle tone Appropriate Atrophy: ________ Hypertrophy: __________ Other: __________________ Edema None Other: _______________________ Spasms None Other: _______________________ Masses None Other: _______________________ Tremors, involuntary movements None Other: _______________________ Inspect for: Gait & Posture Appropriate Other: _________________ Ability to Stand Unassisted Appropriate Other: __________ Use of assistive devices: _____________________ Assess body movements: Movement Moves all extremities Other: ______________ Coordination Movement coordinated Other: ______________ Inspect and palpate the joints for tenderness, warmth, crepitus, edema (soft tissue swelling), movement, ROM -active & passive - FROM, masses, nodules, erythema (redness): TMJ FROM NT Other: __________________ Cervical Spine FROM NT Other: __________________ NURS 3108 Lab Manual 17 Shoulders FROM NT Other: __________________ Elbows - Epicondyles FROM NT Other: _____________ Hands / Wrists (DIPs,PIPs,MCPs) FROM NT Other: ____ Hips FROM NT Other: __________________ Knees FROM NT Other: __________________ Feet & Ankles FROM NT Other: __________________ Inspect and palpate the thoracic & lumbar spine: Alignment Aligned Misaligned: ______________ ROM FROM LROM: _________________ Vertebrae NT Tender: _______________ Paravertebral muscles NT Tender: _______________ Spinal curvatures None kyphosis lordosis scoliosis Scapula, shoulder & iliac crest Symmetrical Asymmetrical: __ Assess muscle strength (___/5) & tone: Upper extremities (UE’s): Biceps Symmetrical Strength= _____ Other: _______ Triceps Symmetrical Strength= ____ Other: _______ Handgrips Symmetrical Strength= _____ Other: _______ Lower extremities (LE’s): Hip abduction Symmetrical Strength= _____ Other: _______ Hip adduction Symmetrical Strength= _____ Other: _______ Plantar flexion Symmetrical Strength= _____ Other: ______ Dorsiflexion Symmetrical Strength= _____ Other: _______ Assess CSMF: C = Circulation - warmth, capillary refill, color, pulses Intact Other: ________________ S = Sensation – distal - light touch, sharp/dull Intact Other: ________________ MF = Motor Function UE/LE strength – Handgrips & Plantar & Dorsiflexion Intact Other: ________________ Vital signs: T__________ P__________ R__________ BP_________ NURS 3108 Lab Manual 18 O2Sat_________________ NURSING NOTE REGARDING YOUR ASSESSMENT WORKSHEET 7 NEUROLOGICAL MENTAL STATUS Observe Appearance & Behavior: (Appropriate to situation) Affect Emotional Status/Mood Eye Contact r: __________ Body Movements Grooming/Dress Assess Mental Status for: Judgment Abstraction – Thought Processes Memory - ST & LT Cognitive Abilities, Concentration, Attention Span & Comprehension Orientation - A & O x 4 -Time, place, person & situation Assess Speech & Language for: Voice Quality Clarity _________ Articulation Coherence & responses appropriate Assess Sensory Function in the UE’s & LE’s: Light touch ct: _____________ Sharp/Dull NURS 3108 Lab Manual 19 Position Sense Number I Name CN I – Olfactory M=Motor/S=Sensory Sensory II CN II – Optic) Sensory III CN III – Oculomotor Motor IV CN IV – Trochlear Motor V CN V – Trigeminal Motor & Sensory Assessment Technique Sensory nerve – smell reception & interpretation Use common objects such as soap, coffee, cinnamon, alcohol swab Gross visual acuity – Snellen chart 20/20 is normal Near Vision – Rosenbaum chart Cranial Nerves III, IV, VI are checked together PERRLA = Pupils round, equal, reactive to light and accommodation Ability to follow smoothly in all 6 fields of gaze Cranial Nerves III, IV, VI are checked together See above Patient can open & close mouth Blinks normally VI CN VI – Abducens Motor VII CN VII – Facial Motor & Sensory Can feel light touch in different regions of face Cranial Nerves III, IV, VI are checked together See above Smile Puff out cheeks VIII CN VIII – Acoustic Sensory IX CN IX – Glossopharyngeal Motor & Sensory Raise eyebrows Whisper test Cranial Nerves IX& X are checked together Patient can swallow saliva normally (no drooling), can swallow food &/or drink Note gutteral voice quality (g, k) X CN X – Vagus Motor & Sensor) XI CN XI – Spinal Accessory CN XII – Hypoglossal Motor XII Vital signs: T__________ O2 Sat: ________________ Motor P__________ If concerned, can observe symmetrical rise of uvula when saying ‘ah’ Cranial Nerves IX& X are checked together See above Raise shoulders Move head side to side Enunciation of words that require the tongue- (l, t, n) R__________ NURSING NOTE REGARDING YOUR ASSESSMENT BP_________ Intact Not Intact NURS 3108 Lab Manual WORKSHEEET 8 Assignment: Focused assessment on Head, Eyes, Ears, Nose, and Throat Client initials______________ Age___________________ Code Status__________________ Allergies_________________ Diet_____________________ Medical Diagnosis: ______________________________________________________________________________ ______________________________________________________________________________ Past Medical History: ______________________________________________________________________________ ______________________________________________________________________________ HEAD & FACE Inspect & palpate head, skull & face: Size & Shape Normocephalic Other: ________________ Symmetry Symmetrical Asymmetrical: ______ (Note tenderness, swelling, bulges) Movement & position Appropriate Other______________ Temporal arteries Pulse palpable No bruits Other: ______ FACE: Affect Symmetry Symmetrical Asymmetrical: _______ Movements Symmetrical Asymmetrical: ______ Color: _______ Cyanosis Pallor Jaundice Other: ___ Lesions/Scars None Other: _____________________ Facial expressions Appropriate Other: __________________ Vascularity Appropriate Increased: _______________ 20 NURS 3108 Lab Manual 21 Edema None Generalized Periorbital Tenderness None Tenderness present: _____________ Nasolabial Folds Appropriate Absent: _____ Other: _____ Tics/Tremors Absent Present: ______________________ CN V – Trigeminal (Both Motor & Sensory): Motor Temporal & Masseter Muscles (open & close mouth) Intact Other: _____________ Sensory Corneal/Blink Reflex (via observation) Intact Absent Light touch sensation in 3 areas Intact Absent (Opthalmic, Maxillary, Mandibular) CN VII – Facial (Both) Motor (smile, cheek puff, raise eyebrows) Facial muscle movement Symmetrical Asymmetrical: ____ Vital signs: T__________ O2 Sat: _______________ P__________ R__________ NURSING NOTE REGARDING YOUR ASSESSMENT Worksheet 9 Head to Toe Assessment Mental Status Exam: (neuro) Inspect ability to: see and hear Inspect appearance and behavior A&O to person, place, time, situation Assess speech & language BP_________ NURS 3108 Lab Manual PERRLA Head, Neck, Face, Nails, Hair Symmetry and external characteristics of eyes, ears, nose and mouth Distended jugular veins Lymph nodes Lungs Lung sounds (anterior and posterior) Inspect effort Cough Secretions Nasal flaring Intercostal retractions Use of accessory muscles Inspect chest: symmetry, skin, pulsations, AP Diameter Clubbing Heart Color Capillary refill Palpate chest wall and precordium Any pulsations, lifts, heaves, Apical impulse APE to MAN S1&S2 Inspect pulses (carotid, brachial, radial, pedal) Assess for edema GI/Abdomen Appearance of abdomen Inspect: pulsations, masses, skin, symmetry, bulges distension& peristalsis Inspect umbilicus Last BM Auscultate BS Auscultate for bruits: aorta Palpate (firmness, distention, nodes, masses) N/V, constipation, diarrhea, flatus Urinary Voiding without difficulty? Color, odor, frequency, amount Incontinence Musculoskeletal It pt weight bearing? Do they use assistive devise? Gait steady or unsteady? Contractures? Swelling or pain of joints? Skin Describe (wounds, scars, dryness, etc.) 22
