NUR 600 Assignment 3.1 Review of Systems ROS Documentation 2
University:
St. Thomas University
NUR 600 Assignment 3.1 Review of Systems ROS Documentation 2
Paper Instructions
Assignment Guidelines
Using the guidelines in Bickley, Components of the Health History, pp. 7-12, obtain and document a complete ROS on a friend. Document Pertinent Positives and Negatives while taking the ROS, using the Components of the Health History found under Present Illness. Include a description with each positive finding on the elicited ROS. Reference pp. 31-33 in the text; the Case of Mrs. N gives an example of this type of write-up to use as a guideline.
Submission
Submit your assignment and review full grading criteria on the Assignment 3.1 Review of Systems (ROS) Documentation page.
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Sample Answer
General
- He reports mild fever and increased fatigue. Negative for chills or weight changes.
Skin
- Negative for skin-color changes, itchiness, rashes, or bruises
HEENT
- Head Negative for headaches or head injury.
- Eyes Reports itchy eyes. No visual loss, blurred vision, double vision, or yellow sclera.
- Ears Reports itchy ears. No ear discharge or hearing loss.
- Nose Positive for itchy nose, sneezing, nasal congestion, rhinorrhea, and postnasal drainage. No nasal bleeding.
- Throat Positive for itchy palate. No sore throat or swallowing difficulties.
- Neck No neck pain or stiffness.
Respiratory
- No cough, sputum production, shortness of breath, or chest pain.
Cardiovascular
- Negative for edema, palpitations, chest pain, chest pressure/discomfort, SOB on exertion, or fatigue.
Gastrointestinal
- No nausea, vomiting, epigastric pain, bloating, abdominal pain, diarrhea, constipation, tarry stools, or rectal bleeding.
Urinary
- No dysuria, urinary frequency, urgency, blood in the urine, or abnormal urine color.
Genital
- Negative for penile discharge, testicular pain, or scrotal swelling. He denies a history of STIs.
Peripheral vascular
- Denies having leg cramps, swelling/tenderness in calves, or a history of varicose veins.
Musculoskeletal
- No joint pain, joint stiffness, muscle pain, low back pain, or history of fractures.
Psychiatric
- He denies having anxiety, depressive, or psychotic symptoms. He denies having an addiction to alcohol or drug substances. No history of psychiatric admission.
Neurologic
- Negative for headache, dizziness, fainting, muscle weakness, constant mood changes, loss of sensation, or tingling sensations.
Hematologic
- Negative for bruising or bleeding. No history of anemia or blood transfusion.
Endocrine
- Negative for heat/cold intolerance, excessive sweating, thinning hair, polydipsia, polyuria, or polyphagia.
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