Free Essay

Comphrensive Phsical Assessment

In: Science

Submitted By lakeyrenna
Words 4211
Pages 17

Linda McGoff
Indiana Wesleyan University
NUR 334: Comprehensive Physical Assessment of the Well Adult
Facilitator: Tracy Kastenhuber
October 31, 2011
Plagiarism Policy

Interview for Health History Guidelines

Student: Linda McGoff Core Group: RNBO142 Date: 10/15/2011

Initials of Client: MEV Sex: Female Age: 79

Present Health Status: Fair
Current medications and/or herbs:
Synthroid 125mcg qd
Cytomel 25mg BID
Neurotin 300mg TID
Plavix 75mg qd
Voltaren 75mg BID
Nexium 40mg qd
Naproxen 500mg BID
Xanax 0.25mg BID
Botox 2000 U given in different areas in the neck

Current treatments:
Treatment for hypothyroidism, hyperlipidemia, GERD, osteoarthritis, anxiety and cervical dystonia

Allergic to Morphine Sulfate - vomiting
History of Present Illness (if applicable):
Left knee pain which is causing difficulty with ambulation & Cervical dystonia aka spasmodic torticollis causing head tilting, neck pain, and neck muscle spasms

Location – Left knee and neck

Character or quality – Left knee pain is described as sharp, grinding sensation with ambulation, reported considerable swelling prior to starting Voltaren medication. Neck has sensation of spasms and involuntary head tilting or movements

Severity-Yes, debilitating

Aggravating or relieving factors: Ambulation causes increase in pain and discomfort. The discomfort is relieved by staying off the leg, elevating also helps. “As for the cervical dystonia, I feel like my life will never be the same again.”

Associated factors: Interfers with my daily activities and hobbies.

Patient’s perception: Debilitating, very frustrating due to “I like to stay busy and this impedes my ability to get things done”. Patient reports that the Voltaren is definitely helping with the discomfort in the knee which will hold off the need for a TKR. She has an appointment with the orthopedic physician for f/u in a few weeks. “The situation with my neck has definitely affected how I feel when around people, my head shakes and I feel like people are staring at me. It has left me feeling uneasy about being in public; I feel I have lost my self-confidence.” She has another appointment for her second round of Botox injections in a few weeks.

Past Health History
Childhood illnesses:
Chicken Pox
Whooping cough

Adult illnesses:
Gastrointestinal infections
Uterine Fibroids

Hospitalizations: (include dates and reasons)
4 live births – 4/2/1953 - daughter 4/22/1955- son 1/25/1958- daughter 5/25/1961- son

Surgeries: (include dates and type)
Hysterectomy – 1969
Hemorrhoidectomy – 1985
R Total Knee – 2000
Coronary artery bypass graft – 1996
Lower back surgery - 1979

Accidents or injuries: (include dates and type)
Sprained R ankle-2010

Chronic conditions:
GERD – treated with Nexium; sleeps w/ head elevated on 2 pillows
UTD- recent tetanus
Flu vaccine – annual
Pneumococcal vaccine

Date of last: Physical exam 6/2011 EKG-6/2011 Chest x-ray – 6/2011 Mammogram-2010

Gynecologic/Obstetric history:
Delivery 1953, 1955, 1958 & 1961- all vaginal
Family History (age and health or age and cause of death)
Parents: Father – deceased- heart failure 1995 – age 78 Mother – deceased-Alzheimers in 2005 – age 86
Paternal Grandmother – deceased-complication of diabetes – age 80 Paternal Grandfather – deceased-unknown cause – age 81 Maternal Grandmother –deceased-unknown cause – age 53 Maternal Grandfather – deceased-cancer –age 46

Brother- age 65
Sister deceased in 2001-renal failure; 1 sister living - age 81
Brother-deceased in 2003 – heart attack

Parents’ siblings: all deceased

Nutritional Status
Height: 65” Weight: 142
Diet pattern: Breakfast Cereal, oatmeal or danish Coffee and juice

Salad or soup or sandwich Ice tea
3 course meal, a meat, 2 vegetables and a bread
Ice tea or diet coke

Pudding, fruit, ice cream or sherbert Fluid intake – coffee, tea, water, juice or soda

Cultural and Ethnic Information: German/French decent
Influence of Language or communication Skills:
What languages do you speak at home? English In public? English
How well do you speak English? Fluent Read English? Very well Write English? Very well
Who is your family spokesperson? Spouse
Comments: “He is my strength, he is there for me to lean on.”

What religion or faith do you practice?
How important is this to you? “Extremely”

Are there special beliefs or practices that would be helpful for us to know while treating you if you become ill? “Communion is important if I were to be hospitalized for a lengthy timeframe.”

Comments: Chaplin if desired

Health Practices:
Do you use any alternative treatments for healing? No

Is there anyone special that you turn to when you are sick? Spouse

Comments: “My spouse and I are very close. We care deeply for one another; we want to be there for each other. We have been together since we were early teenagers.”

Describe your family: “Very loving, also very close; there is much concern for each other.”
Who makes family decisions? “It is discussed and the final decision is left to my spouse.”
What are the roles and responsibilities of other family members? “They are always available in times of need. I can always count on them.”
Comments: “Everyone works hard to make themselves available in times of crisis or illness.”
Assessment: Performed on 10/22/2011
Vital Signs: Temperature: 98.4 (oral) Pulse: 84 bpm (radial)
Respiratory rate: 22 bpm
BP: 138/84 (L arm)
Patient is oriented to person, place, and time. Patient has given permission for this assessment performance.

Review of Systems (Check all that apply and explain)
Skin: ___Skin disease ___Changes in skin ___Bruising
___Lesions ___Sores ___ Changes in moles ___Hair loss
___Change in hair texture ___Changes in nails
Subjective: Describe exposure to sun: Client reports minimal exposure; mainly when I play golf in the spring and summer.
Objective: Skin is olive in color, smooth, thin, dry and soft to touch. Noted a some age spots on arms, hands and a few on face. Client looks younger than stated age. Inspection reveals no lesions or rashes. No ecchymosis or open wounds. Skin turgor recoils < 2 seconds. No edema. Nail surface is slightly rounded and smooth, length short, clean w/ uniform thickness bilaterally; color pale pink, capillary refill < 3 seconds.

Head: ___Dizziness ___Fainting ___Headaches ___Injury
Subjective: Client reports no headache, dizziness, light headedness or injury.
Objective: Upon inspection, the head is symmetrical, shape is oval and head has consistent movement. Scalp has no flaking. Hair distribution is slightly thinning. No lumps or lesions noted upon palpation. Eyebrows have been shaved and have been permanently tattooed. Eyelashes are light and normal in distribution. Palpation of temporal artery one side at a time, the artery is elastic w/o tenderness. Palpation of the temporo-mandibular joint revealed no swelling, pain or tenderness. The patient was able to smile/frown, blow out cheeks, tightly close eyes, shows teeth indicating the CN VII intact. Palpation of maxillary sinuses and frontal sinuses reveal no tenderness. Using a dull and sharp point of a paper clip, patient was able to distinguish the difference between sharp and dull sensation on side of cheeks, forehead and chin while eyes closed. This reveals that the CN V is intact.

Eyes: __X_Corrective lens Type: Glasses
___Discharge ___Swelling ___Redness ___Pain ___Infection
___Excessive tearing ___Visual changes ___Sensitivity to light
___Flashing lights ___Halos around lights ___difficulty reading
___Cataracts ___Glaucoma ___ injury ___other
Subjective: Client reports no problems with sight if wearing glasses.
Objective: Using the Snellen chart, the client is unable to see the letters w/o glasses.
Using prescribed corrective glasses, the patient is able to read 20/20 in L eye (R eye covered) and 20/30 in R eye (L eye covered). On inspection the eyes look in proper position and aligned bilaterally. Lacrimal inspection reveals no drainage, enlargement or redness. Using a pen light approx 14 inches from the patient; she is asked to focus on an object as the light source is shown on forehead-Corneal reflex is symmetrical bilaterally. Sclera white, no redness, no opacities, or discharge; conjunctiva transparent w/ small blood vessels, no drainage or lesions. Inspection of iris-blue color, clear cornea and dark pupils measured 3.0 mm; to test pupil reaction to light, using a pen light; shine the light into L pupil-brisk reaction, then R pupil-brisk reaction. PERRLA intact, lens transparent. Using a pencil; she is asked to follow a pencil as it is moved, but don’t move head. The patient is able to follow the pencil up, down, left, right and in to the front of the nose. Ocular movements intact. Using the ophthalmoscope to inspect the fundus which is the back of the eye; the blood vessels are noted and lead directly to the optic disc; unable to distinguish between the vessels; macula dark.

Ears: ___Pain ___Excessive wax ___Infection ___Ringing
___Sensitivity to noise ___Hearing aid use ___ Earaches
Subjective: Client reports no issues with hearing.
Objective: The patient’s ears are normal in appearance and symmetrical in position. The auricles are palpated w/o nodules. The tragus is normal in size and the lobules are meaty and of moderate size. Palpation of mastoid process reveals no tenderness. Using an otoscope to view inside the ear canal, external auditory canal is pink and the tympanic membrane is translucent grey. Patient is able to hear a whisper and repeat the word voiced to her. Rinnes test reveals air conduction greater than bone conduction.

Nose / Nasopharynx / Paranasal sinuses: ___Discharge ___Nosebleeds ___Pain
___Unusual sneezing ___ Nasal obstruction ___Snoring
___Change in sense of smell ___ Allergies or hayfever
Subjective: Client reports no current problem w/ sinuses; has a history for sinus infections. She is able to smell w/o difficulty.
Objective: Nose is midline. No obstruction w/ R or L nostril. Client able to accurately differentiate soft sweet smells from strong ammonia smells. CN I intact. Inspection of internal nose reveals pink moist mucosa, no sores, no drainage noted. With the use of a pen light -transillumination of the maxillary sinuses reveals no excess fluid, inflammation or infection.

Mouth / Oropharynx: ___Sores ___ Bleeding gums ___Change in taste
___Swallowing problem ___Chewing problem ___Dental prosthesis
___Frequent sore throats ___ Toothaches
Subjective: Client reports no problems w/ taste. No problems w/ swallowing. Client reports that she has false teeth which do not impede chewing of foods.
Objective: Client able to drink a sip of water and swallow w/o difficulty. Open mouth inspection reveals buccal mucosa w/ moist membranes. Tongue is midline and pink. Wharton’s ducts noted under tongue. Lingual frenulum noted, no lesions, sores or abscesses seen. Client able to press tongue against tongue blade. This shows that CN IX and X are intact. Dentures in place. Hard and soft palate concave and pink in color. No lesions or bleeding noted. Client asked to say “Ahh” w/ mouth opened wide, the uvula and the soft palate rise symmetrically. Throat pink and moist, Gag reflex present. Lips are smooth, thin w/o cracking.

Neck: __X_Pain ___Swelling __X_ Limited movement __X_Stiffness
___Lumps ___Lymph node enlargement
Subjective: Client reports suffering w/ severe neck pain for approximately one year. No injury; just awakened this way. Felt she slept wrong. After weeks of discomfort w/ no improvement, the client went to her physician. He recommmended she attend pain management. The treatment was a series of three (3) epidural steroid injection in the cervical region. The first two were completed w/o problems. The client states the following :
”It didn’t help the pain much but I hoped the third injection would be more successful. This didn’t happen ; instead a nerve was hit and a sharp burning sensation went down my left arm.’ She states, ‘I was left w/ neck and head instability and my head shakes like I have Parkinson’s disease and my neck muscles are weak, so I need help w/ mobility for safety reasons. I have since had 1 series of Botox to aid in relaxation of the muscles that control my neck and head. This is suppose to stop the shaking but not as yet. Upon akwning in the morning I sometimes feel stiffness in my neck. This experience has left me feeling like I’ve lost my independence. ”
Objective : Inspection of neck reveals consistent movement of neck and head. Client is able to flex neck, extend neck and turn head from L side, then to the R side. This is done slowly so not to cause discomfort. Strength in neck muscles-slightly weak. No lesions, lumps, nodules or masses. Trachea is midline, palpation of thyroid gland reveal no goiter. Palpation of six lymph areas as follows : In front of the targus are the preauricular lymph nodes-no swelling. Behind the ear are the postauricular lymph nodes – no swelling, located at the junction between the back of the head and neck are the occipital lymph nodes-no swelling; located along the underside of the jaw on either side are the submandibular lymph nodes-no swelling; located just below the chin are the submental lymph nodes-no swelling; and the tonsillar lymph nodes are the same as the submandibular. No lymph node abnormality.

Arms, Hands and Fingers:
Subjective : ‘I have no problem using my arms, hands and fingers. I am able to pick things up w/o difficulty. I have not been dropping any items, except when clumsy.’
Objective : Skin is olive in color, smooth w/ some wrinkling, dry and soft to touch. Able to shrug shoulders and turn head against resistance. No tenderness in bilateral shoulders/arms. No ecchymosis, swelling or lesions. ROM intact at elbows wrists and fingers. Palpation of brachial, ulnar and radial pulses-regular, inspection of palms of hands are pale pink, warm and dry. A percussion hammer (reflex hammer) used to test deep tendon reflexes of biceps, triceps, and brachioradialis sites – each 2+ quick response. Rapid alternating movement of anterior hands on bilateral thighs and lift up hands and turn over so anterior of hands is facing up. Client able to do this in sequence of 10 w/o difficulty. Stereognosis intact- graphesthesia intact.

Cardiovascular: ___Chest pain ___Palpitations ___ Dyspnea on exertion
___Hypertension ___Hypotension ___Orthopnea ___ Cyanosis
Describe fat and salt intake: Client uses minimum amount of salt.
Subjective: Client reports history of chest pain, and abnormal heart palpitations. History of angioplasty and CABG 1996. No current chest pains/abnormal palpitations.
Objective: Upon inspection of sternal area, there is a healed vertical scar from previous CABG. On jugular palpable, pulse noted, no distension or bulging. Apical pulse palpated at the left fifth intercostals space at the left mid clavicular line. Apical heart rate auscultated with stethoscope just below the nipple line- Apical pulse rate 86 beats/min, regular rhythm, S1 noted at apex.
The aortic area region auscultate at the chest wall between the 2nd and 3rd intercostal spaces at the right sternal border. Pulmonic area auscultate between the 2nd and 3rd intercostal spaces at the left sternal border. Tricuspid area auscultate between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternal border. Mitral (apex) area auscultate between the 5th and 6th intercostal spaces in the mid-clavicular line. Erb’s point is the 3rd intercostals space just left of sternum. Regular rhythm w/o murmur or gallop, S1 S2 heard sounds. Finally, client asked to lay on her left side, using bell of stethoscope listen to apex of heart at the at the 5th and 6th intercostal space - regular rate.

Peripheral: ___Coldness ___Edema ___Discoloration
___Varicose veins ___Leg pain ___ Numbness or tingling
Subjective: Client reports that her L lower leg is larger than her R since her CABG. She states that ‘it always looks swollen since the surgery. Since surgery always looks larger than R leg.
No pain or discomfort and no numbness or tingling’
Objective: On inspection, no skin discoloration, legs are shaved, left lower extremity appears slightly swollen, this leg used to retrieve the saphenous vein during her CABG. L foot appears swollen. No varicosities, some spider veins noted on thigh and calf bilaterally. Able to move legs up, down, R and L- bilaterally, feet flex and extend. ROM intact. Epitrochlear nodes are non-palpable bilaterally. Femoral pulses, popliteal, posterior tibial and dorsalis pedis pulses all 2+ bilaterally. Toe nails thick, trimmed, pressure on nail bed – capillary refill < 3 seconds bilaterally. Plantar surface sensitive to sharp and dull sensation w/ use of paper clip. Patellar reflex-quick response bilaterally.

Respiratory: ___Colds ___Dyspnea ___Cough ___Wheezing
___Pain ___Night sweats ___Coughing blood ___ Sputum (color, amount)
Subjective: Client reports no current cold, cough or difficulty breathing. Former smoker from age 15 to 55 years x 2 ppd. Quit x 24 years.
Objective: On inspection anterior chest symmetrical. Sternum midline. Pinched skin above sternum-released; skin turgor < 2 seconds. Respirations relaxed and even at 22 bpm. No retractions at intercostals spaces, no accessory muscle use. Chest inspiration and expiration symmetrical. On palpation no pain, tenderness, crepitus or masses. Auscultation of breath sounds reveal no rales, rhonchi or wheezes. Lungs clear bilaterally. Percussion of posterior thorax is resonate, the level of diaphragm dullness distance between full inspiration and full expiration is 4 cm. Evaluation of chest expansion at levels T9 and T10.

Gastrointestinal: ___Nausea ___Vomiting __X_Indigestion ___Pain ___Diarrhea
_X__Constipation ___Flatus ___Change in appetite ___Change in ability to taste
___Change in stool ___Change in bowel pattern
Describe usual bowel pattern or routine: Client is often constipated, uses Metamucil to assist w/ bowel movements.
Subjective: Client reports that she has problems w/ indigestion, occasional nausea and frequent constipation. “Some foods make me sick to my stomach.”
Objective: Client lying in supine position. Abdomen is observed round, symmetrical bilaterally. Color is olive, old faded striae, no rash or lesions. Umbilicus is midline w/o discoloration. Auscultation of all 4 quadrants performed; notable bowel sounds heard every 10-30 seconds. Moderate gurgles. No friction rubs heard over liver aorta, iliac artery, umbilicus femoral artery and spleen. On light abdominal palpation – abdomen soft, no tenderness or guarding. Abdominal reflex present. No pulsations of abdominal aorta. No bruits of abdominal aorta or bilateral femoral arteries.

Urinary: ___Urgency ___Frequency ___Hesitancy ___Dysuria
___Change in stream ___Hematuria ___Polyuria ___Nocturia
___Oliguria ___Pelvic pain ___Flank pain
Describe usual bladder pattern or routine: “Several times throughout the day, I see it as normal, nothing excessive. Most nights I may wake up once to go to the bathroom”
Subjective: Client reports no burning, frequency, urgency or abnormal urinary problems. No pelvic pain. Urine is described as clear yellow.
Objective: Not observed



Musculoskeletal: ___Pain ___Weakness ___Cramps ___Spasms
__X_Joint pain ___Swelling ___Joint deformity ___Back pain __X_Limitation in movement __X_Limitation in activity
Describe exercise pattern or routine: Reported L knee pain and discomfort; also cervical dystonia
Subjective: Previously mentioned my problem w/ L knee pain and discomfort; also my cervical dystonia condition.
Objective: Inspection of posterior spinal region, midline. No curvature. Client able to stand w/o instability, posture correct, no humpback, ambulates with short strides, arm swings appropriate. Tandum walk intact. Able to hop on R leg, however, client request not to hop on L leg due to L knee discomfort. Romberg’s test is negative, minimal swaying with eyes closed while standing still. Able to touch chin, forehead, cheeks and nose appropriately with eyes closed.

Central Nervous System: ___Pain ___Seizures ___Fainting
___Dysarthria ___Dysphasia ___Change in Memory ___Paresis
___Paresthesia ___Paralysis ___Loss of coordination ___Hallucinations
Subjective: Patient reports no numbness or tingling in extremities. No current loss of gait coordination; however, “post Botox procedure, I needed help w/ walking due to neck completely flaccid. Client wore a neck brace to assist w/ balance of head.” Client states, “ I feel my memory is fine, but my spouse says I am forgetful”
Objective: Neck muscles remain slightly weak. Speech is understandable, no paralysis noted, coordination is currently OK. Memory recall- slowed w/ age.

Endocrine: ___Weight change ___Polydipsia ___Polyuria
___Anorexia ___Hormone therapy ___Change in hair distribution
___Heat or cold intolerance __X_Change in skin pigmentation
Subjective: Client states “I went through menopause years ago” No current issues other than I am diagnosed as hypothyroid and I take medication for it daily.” Objective: On inspection and palpation, skin warm and dry, intact, numerous age spots on hands, arms and scant amount on face. Thyroid gland palpable, no goiter. Hair on arms is fine and scant.

Functional Assessment
Education- high school
Financial status-husband retired, investments, doing OK
Value/belief system-Catholic
Comments: I don’t try to force my beliefs on others

Activities of daily living- I don’t do much since my neck problem started.
Use of wheelchair ___ Prosthesis ___ Mobility aids __X_
Comments: Uses cane if she feels a little unstable

Sleep pattern-tried to get 7-8 hours per night
Daytime naps-rarely
Sleep aids used - none

Interpersonal relationships
Social roles – not as social since the neck problem; I feel self conscious.
Family – very important, rely on them only when necessary
Friends – have a few long time friends
Organization(s) - none
Workplace - retired
Comments: Feels like this incident causing the neck problem has destroyed the life she once had.

Coping and stress management
Stresses in life – current medical situation (cervical dystonia)
Methods to relieve stress – try to take one day at a time; watch more TV than normal
Comments: Soap operas help take her mind off of her own problems if only for a little while

Personal habits
Tobacco ___ Alcohol ___ Street Drugs ___
Comments: Rarely drink

Environmental Health
Occupational hazards: n/a

Home safety: Lives in a 1st floor condo, husband retired, no throw rugs

Neighborhood safety: Neighborhood watch program

Travel safety: No current traveling, other than to/from physician’s office or friends and family.

Analysis and Care Plan
Mrs. V. is a 79 year old female with a diagnosis of cervical dystonia and left knee osteoarthritis. The client was previously active and social. She is 5'5" in height and her weight is 142 lbs-a BMI of 23.6 which is in the normal range. Her most recent problem is her head shaking and weakness in the neck muscles. The client looks much younger than her years. It is obvious that she is very concerned about her appearance. She previously exercised 2-3 days per week at a gym. This condition has caused her to be unstable at times; when this occurs she needs assistance with mobility and normal daily activities. She reports being very self-conscious, frustrated and feels like her life will never be the same. She takes medication to help her relieve her anxiety. This is a very sad situation for this client.
Subjective: 79 years of age Diagnosed with cervical dystonia and osteoarthritis of left knee “Neck weakness” Reports “Left knee pain and difficulty walking, uses a cane when needed” “Anxious and frustrated” Client states “feeling like people are staring at her” “I am unable to drive now” Reports “I need assistance w/ everything” “I feel like my life will never be the same”
Objective: Elderly female Head bobbing/shaking Embarrassment Client feels self conscious Instability - moderate Slight limp, using cane Slow ambulation Uses caution when ambulating, getting up or sitting down

Data for Nursing Diagnosis- #1:
Subjective: Objective:
Diagnosed w/ “cervical dystonia” shaking of head and neck
“Feels like people are staring at her” moderate instability Reports “neck weakness” neck brace for stabilization
“Feels anxious and frustrated” cautious w/ ambulation neck brace for stabilization dependency on spouse & family

Nursing Diagnosis: Personal Identity Disturbance r/t head shaking as evidence by dependence on spouse, or family for assistance; and, comments pertaining to frustration, anxiety and self-consciousness.
Goal: Patient will verbalize acceptance of diagnosis and decrease in anxiety and frustration by 3 December, 2011. Interventions:
1) Nurse to make referral to disease management to aid in determination of potential needs and develop a more complex treatment plan.
2) Nurse will encourage patient to join a support group; patient will agree to review the support group information and contact them. The patient realizes that she needs to develop improved coping skills.
3) Nurse will support group patient participation to ventilate feelings, concerns and fears. Patient will be receptive to group member suggestions .

Outcome: Patient will report that attending the support group was helpful in helping her to understand the disorder and also provided her a support network of friends who truly do understand her type of life circumstance crisis.

Data for Nursing Diagnosis #2:
Subjective: Objective:
“I need assistance” Difficulty walking
“I use cane when needed” slight limp neck muscles are weak moderate instability
Left knee pain weakness-neck and knee/leg
Nursing Diagnosis: Potential for Injury r/t pain and weakness as evidenced by difficulty walking, moderate instability, cane use as needed, slight limp and voiced “needing assistance”.
Goal: Patient will remain aware of weaknesses, use cane whenever feeling unstable and request for assistance with any attempt to ambulate.
1) Nurse will provide constant reminders for spouse and family regarding safety.
2) Nurse will encourage patient to allow home health PT personnel to perform a safety consultation regarding potential hazards in the home.
3) Nurse will encourage patient to ask for assistance from family and spouse when necessary.
Outcome: The client will obtain no injuries.


Weber, J. & Kelley, J, (2010). Health assessment in nursing (4th ed.). Philadelphia, PA Lippincott Williams & Wilkins.

Similar Documents