Free Essay

Physical Assessment

In: Other Topics

Submitted By robinson01
Words 287
Pages 2
Physical Assessment
Mental Status: My patient is alert and knows his orientation. He is coherent and is able to recall recent and remote events. He appears healthy and shows no signs of distress or anxiety.
Skin & Nails: His skin appears to be tanned in color. There is no bleeding or a rash present but has a dime size contusion on right bicep. No signs of puffiness or pitting on the skin. The skin has a smooth texture with a warm touch and doesn’t appear too dry or moist. Patient doesn’t show any signs of dehydrations which means turgor is great along with skin mobility. The nails are pink in color and well cleaned. The branch test shows great capillary refill and no signs of nail clubbing and has an angle of 150 degrees.
Head: The patient’s hair is brown with little gray in it. No signs of hair loss and appears clean and shiny. He has no lesions, lice, or lumps present. The scalp appears to have normal distribution of hair on it. Face shows symmetry with appropriate facial movements and CN VII is intact. The patient has sensation in all six locations which indicates CN V is intact. The contraction of the masseter and temporal muscle feel normal and appear symmetrical and has no signs of temporomandibular joint disorder.
Neck: The patient had no difficulties completing range of motion. He has no masses/scars present and symmetry appears great. All nodes feel within normal range and no signs of swelling or inflammation. The trachea is mid-line, thyroid gland is normal without masses, and no goiter. Patient has no problems with trapezius and sternocleidomastoid muscle strength and CN XI appears to be intact as well.

Similar Documents

Free Essay

Complete Physical Assessment

...| Complete Physical Assessment | Fort Hays State University | NURS603L Health Assessment Across the Lifespan Lab for RNs | Katie Houp | 4/24/2014 | Complete Physical Assessment of 40 year old male patient seen for assessment purposes. | Complete Physical Examination Date: 4/24/2014 Examiner: Katie Houp Patient: Matt Gender: M Age: 40 Occupation: Medic General Survey of Patient Patient is Alert and Orientated to time place and events, appears slightly younger than stated age of 40 years old. Is of African American descent with medium brown pigmentation. Appears well nourished, denies any unplanned weight changes in recent months. Posture and Position: Sitting straight, relaxed with interview process, Obvious Physical deformities: None. Mobility: gait is even, able to ambulate without assistance or use of assistive devices. Full ROM of Joints noted, no involuntary movements noted. Facial expression: Relaxed, pleasant, Mood and affect: laughs with examiner, appropriate for situation. Speech: Clear, even cadence, appropriate word choice, English is noted to be secondary language. Hearing: able to hear whispered words without difficulty. Personal Hygiene: no malodorous smells identified. Measurement and Vital Signs Weight: 160 Height: 5’8” Body Mass Index: 24.3 Radial pulse palpated rate and rhythm: strong and regular Blood pressure: Right arm 118/62 Respirations: observed regular rate and rhythm. Temperature: not obtained this......

Words: 1469 - Pages: 6

Free Essay

Physical Assessment Narrative

...Matt Physical Assessment Narrative November 22, 2014 Client resting in semi-fowlers position. Hand hygiene performed and verification of client by two identifiers (Name, DOB) are matched with I.D. band to confirm client. Client assessed for allergies and concerns and reports no concerns or allergies. Client is Ox3, LOC is alert, shows PERRLA, and EOMS intact in all fields. Glascow Coma Scale assessed to be a perfect 15. Client grips are 5/5 (B) in hands and feet. Homans sign neg, and no bruising, scars, lesions, ulcers, edema noted. Skin is warm and dry and mucous membranes appear pink and moist. Client has intermittent IV in left antecubital region with no fluid intake and client asked if he had anything to drink within last couple hours and he states “I’ve had a 12oz coke” (I said mL in video and meant to say Oz). Intake documented to be 360mL. Client voids using BSC. 200mL of clear, amber urine present in BSC and documented as output. Radial and pedal pulses are palpated and found to be 2+ (B). Client asked about diet and he states he is on a regular diet. Heart sounds auscultated without extra heart sounds and apical pulse assessed to be 66 regular. Respiration rate of 16 with eupneic pattern. Bowel sounds auscultated to be normoactive in all 4 quads. Lungs clear to auscultation in all 5 fields A-P-L. Client wears no corrected lenses/glasses, or hearing aids and no drainage from eyes or ears are noted. ROM full in all areas and gait appears to be steady. IV site......

Words: 324 - Pages: 2

Free Essay

Physical Assessment

...D. Physical Assessment Findings VITAL SIGNS | Normal Finding | Outcome | Analysis | Body Temperature | 36.5-37.5 C | 38.1 C | Hyperthermia indicates sign of infection | Pulse Rate | 60-100 bpm | 68 bpm | Normal | Respiration | 12-20 cpm | 20 cpm | Normal | Blood Pressure | 120/80 mmHg | 160/80 mmHg | Increases Blood Pressure indicateshypertension | HEAD TO TOE ASSESSMENT Area Assessed | Normal Findings | Actual Findings | Analysis | 1. Skull A. Inspects skull for 1. size 2. shape 3. symmetry B. Palpates for tenderness of mass/nodules, depressions and tenderness | Rounded (normocephalic & symmetrical with frontal, parietal, and occipital prominences: smooth skull contour)Smooth, uniform consistency Absence of nodules or masses | My client has a rounded skull usually normocephalic & symmetrical with frontal, parietal, and occipital prominences. She also has a smooth skull contour | The skull is rounded and smooth thus it is normal. | 2. Hair and Scalp A. Inspects for 1. Color of Scalp 2. Odor 3. Presence of dandruff infection 4. Lesions B. Inspects for 1. Color of Hair 2. Distribution 3. Thickness/ Thinness 4. Texture 5. Oiliness 6. Presence of lice, nits, split ends 7. Length | Evenly distributed Thick hair Silky, resilient hair (-) infection(-) infestations | The scalp of my client is......

Words: 3132 - Pages: 13

Free Essay

Physical Assessment

...Patient: VH Temperature: 36.2 Pulse: 82 Respiratory Rate: 21 Blood pressure: 129/68 Pulse Ox: 91.0% Pain Score: 0/10 Allergies: NKA Code Status: DNR Weight: 61.47Kg Height: 60” BMI: 26.75 Diet: Regular supplement per facility protocol, fluid restriction to 1500cc every day Ethnicity: White Religion: Protestant General: Alert, oriented x3, awake, healthy appearing. Supine position on bed. No respiratory distress. Ambulatory aide is a walker, ambulating normally. Mental Status: Judgment and insight intact; oriented to time, place, and person; intact memory for recent and remote events. Head/Hair: Head is normocephal. Hair appears thin and gray. Scalp no signs of abrasions, masses or deformities, scalp is not dry, hair distribution even, hair free of infestations. Nails: Finger nails long, appearance of striae, surface has ridges. Capillary refill of 2 seconds, nails slightly rounded. Little black circle on left pinky above proximal nail fold. Toe nails long, thickened, yellowish color. End of toe nails are chipped, capillary refill of 1.5 seconds. Skin/Extremities: Warm to touch, dry, color is normal for patient’s ethnicity. Skin turgor elastic, and rapidly returns to original shape. Patient has scattered bruising on top of both thighs and up and down arms bilaterally. Fluid filled blisters and open sores scattered on both lower legs and feet bilaterally. Scabs scattered on lower legs and feet bilaterally, 70% yellowish drainage from......

Words: 541 - Pages: 3

Free Essay

Physical Assessment Essay

...Health Assessment Physical Assessment Techniques Evaluation Form Assessment Area | Individual Items to AssessDemonstrate the correct technique for assessing the following: | Points/Points Possible | Measurement and Vital Signs | * The candidate asks the patient their weight. * The student takes the vital signs (pulse, respirations, and blood pressure). | /2 | Skin – | * Hands and nails * Color and pigmentation * Temperature
 * Moisture
 * Texture
 * Turgor
 * Any lesions | /7 | Head and Face | * Scalp, hair, cranium * Face (cranial nerve VII) * Temporal artery * Temporomandibular joint * Maxillary sinuses * Frontal sinuses | /6 | Eyes – describe in your video how you would use the ophthalmoscope to find the corneal light reflex. | * Visual fields (cranial nerve II) * Extraocular muscles (cranial nerves III, IV, VI) * Corneal light reflex * Cardinal positions of gaze * External structures * Conjunctivae * Pupils | /7 | Ears – Describe in your video how you would perform the Weber and Rinne tests for hearing. | * External ear * Any tenderness * Conduct the voice test (cranial nerve VIII) | /3 | Nose – Describe in your video how you would use a speculum to evaluate the nasal mucosa, septum and turbinates. | * External nose * Patency of nostrils
 | /2 | Mouth and Throat | * Lips and buccal mucosa * Teeth and gums * Tongue
Hard/soft palate * Tonsils
 * Uvula (cranial nerves IX, X)...

Words: 573 - Pages: 3

Free Essay

Cardiopulmonary Physical Assessment

...1. What cardiopulmonary physical assessment findings might be present in a patient who smokes? How would you approach this patient for history taking and assessment? There are several physical assessment findings in patients that smoke and a through respiratory and cardiovascular physical exam should be conducted. Dyspnea, coughing with our without sputum, and wheezing may be indicative of a respiratory disease related to smoking. Also, smokers may have a barrel chest, hypoxia, and take much longer to exhale a full breath. More severe assessment findings would include accessory muscle use, pursed lip breathing, tri-poding, and nail bed cyanosis. A complete family history, patient medical history and history of present illness should be obtained followed by a complete set of vital signs. Observe the rate, depth and rhythm of respirations. Note the shape and configuration of the chest wall. Severe thoracic deformities, such as scoliosis and kyphosis may reduce the lung volume. Observe the position your patient is in while at rest to take a breath. A relaxed position and the ability to support ones own weight with arms comfortably at the sides. Patients with respiratory diagnoses may sit in a tripod position (leaning forward with arms braced against knees, chair or bed). (Jarvis, 2012 p422.) Assess skin color; a bluish discoloration (cyanosis) can indicate hypoxia. Assess chest expansion by placing your hands on a patient’s posterolateral chest. Gently bring your thumbs to...

Words: 391 - Pages: 2

Premium Essay

Newborn Physical Assessment

...physical assessment of a newborn is very important because it focuses on normal and abnormal findings. Observing the head’s shape is important because of the molding that happens in majority of births that occur vaginally. There are many things that can occur to a newborn resulting from birth trauma causing unusual masses or prominences. Two most common types of birth traumas that can occur during birth are caput succedaneum or cephalhematoma. The most commonly observed scalp lesion is caput succedaneum, a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery (Hockenberry & Wilson, 2011, p 280). It more likely to form during a long or hard delivery. The swelling extends beyond the sutures and can be associated with petechiae or ecchymosis. Most of the time, the problem is noticed after birth. No treatment is needed. The problem usually goes away on its own within a few days. Complications may include a yellow color to the skin. A cephalhematoma forms when blood vessels rupture during labor or delivery to produce bleeding into the area between the bone and its periosteum (Hockenberry & Wilson, 2011, p 281). Cephalohematomas are more common in first pregnancies, if the baby's head is larger than the birth canal. It gets better with no treatment within 3 months. The boundaries of the cephalhematoma are distinguishable and do not extend beyond the limits of the bone. Hyperbilirubinemia may result during......

Words: 263 - Pages: 2

Premium Essay

Physical Assessment Study Guide

...PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Nursing Assessment 1. Part of Nursing Process 2. Nurses use physical assessment skills to: a) Obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolve b) To identify and manage a variety of patient problems (actual and potential) c) Evaluate the effectiveness of nursing care d) Enhance the nurse-patient relationship e) Make clinical judgments Gathering Data Subjective data - Said by the client (S) Objective data - Observed by the nurse (O) Document: SOAPIER Assessment Techniques: The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the abdomen which is Inspect – Auscultation – Percuss – Palpate. A. Inspection – critical observation *always first* 1. Take time to “observe” with eyes, ears, nose (all senses) 2. Use good lighting 3. Look at color, shape, symmetry, position 4. Observe for odors from skin, breath, wound 5. Develop and use nursing instincts 6. Inspection is done alone and in combination with other assessment techniques B. Palpation – light and deep touch 1. Back of hand (dorsal aspect) to assess skin temperature 2. Fingers to assess texture, moisture, areas of tenderness 3. Assess size, shape, and consistency of lesions and organs 4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep C. Percussion – sounds produced by striking body surface 1. Produces different notes depending on underlying mass......

Words: 14995 - Pages: 60

Premium Essay

Health History and Physical Assessment

...National Patient Safety Goals On Reduce Your Risk of Falling Joanna Dela Pena NR224 Chamberlain College of Nursing Introduction Falls are a public health problem worldwide. Hospitalization increases fall risk because of the unfamiliar environment, illnesses, and treatments. Patient falls and fall-related injuries are devastating to patients, clinicians, and the health care system. A single fall may result in a fear of falling and different complications that will reduced mobility, leading to loss of function and greater risk of falls. Older adults are more likely to be injured from a fall.  Injurious falls also increase hospital costs and lengths of stay (Bates DW, Aug 1995). Factors affecting fall especially in older adults like environment or health care setting, are rising their numbers simply because of inconvenient structures of facility. Older patient that needs to wake up at night struggling to find their call light for help would literally just go to the bathroom by themselves. Without their full cognitive thinking ability to turn on any light and not able to hold their urine because of many reasons like incontinence, would result to fall accidents. People of any age can also be risk from fall injuries due to many psychological and physiological changes they are into. Changing medications for example could make a person dizzy because the body has not adjusted yet to the change. That person could not be aware of the adverse effect and still would do his/her......

Words: 843 - Pages: 4

Free Essay

Complete Nursing Physical Assessment

...ASSESSMENT Gather Equipment/Provide Privacy/Ensure Proper Lightening Wash Hands Ensure visualization of each body part as its examined Introduce self to patient (my name is….. how are you doing today) General Survey Say all of this… Can you state your age for me? Client appears to be stated age. LOC-Ask client: Can you tell me you name please, DOB, and where are you today, what month and year. Client is alert and oriented x3 -- to person, place, time Client’s skin color appears like pink and evenly pigmented without lesions or redness Client nutritional status appears appropriate for weight, height and body size. Client is sitting upright and appears to be relaxed and comfortable Clients body parts are intact and appear equal without no obvious physical deformities. Client is cooperative and smiling, expresses her feelings appropriate to the situation. Client’s speech is in a moderate tone, clear, and culturally appropriate. Upon general observation clients hearing is intact, she hasn’t asked me to repeat anything. Clients dress is appropriate to the season and client is cleaned and well groomed Ask her to walk a few feet and then walk back… State “ Gait is rhythmic and coordinated, with arms swinging at side., walk is smooth and well balanced” Posterior Lungs – stand behind client State out all parts as you inspect. Inspect rhythm, depth and pattern of breathing. State I’m going to inspect respirations for depth, rhythm, and pattern. Client’s......

Words: 5413 - Pages: 22

Premium Essay

Farewwelllll

...An outcomes-based approach to education clearly specifies what students are expected to learn and arranges the curriculum such that these intended outcomes are achieved (Harden, 2007). Learning outcomes provide the base for an effectively aligned and integrated curriculum, where instructional activities and assessment strategies are explicitly linked to course-specific and degree-level learning outcomes, which are tied to institutional and provincially-defined graduate degree level expectations (DLEs). Learning outcomes provide a powerful framework upon which to structure curricula. According to Harden et al., (1999; 2007a) learning outcomes: * help to provide clarity, integration and alignment within and between a sequence of courses; * promote a learner-centred approach to curriculum planning; * encourage a self-directed and autonomous approach to learning, as students can take responsibility for their studies, and are able to actively gauge their progress; * promote a collegial approach to curriculum planning, as instructors collaborate to identify gaps and redundancies, * ensure that decisions related to the curriculum and learning environment are streamlined; * foster a philosophy of continual monitoring, evaluation and improvement; and, * help to ensure accountability and assure quality of our education programs. An aligned curriculum organizes structures and sequences courses around the intended learning outcomes. In order for this......

Words: 824 - Pages: 4

Free Essay

5 Components of Fitness

...Task A-2 Lesson Plan Format Name: Date: 02/0714 Age/Grade Level: 3rd grade # of Students: Program: Physical Education Major Content: 5 components of fitness Lesson Length: 30 minutes Unit Title: The 5 Components of Fitness Lesson Title: Cardio/Body Composition Context • Explain how this lesson relates to the unit of study or your broad goals for teaching about the topic. - This lesson focuses on cardiorespiratory endurance and body composition, which are two of the 5 components of fitness. This lesson will allow students to understand what both components of fitness. • Describe the students’ prior knowledge or the focus of the previous lesson. - Students have briefly been taught the 5 components of fitness in second grade, but have little prior knowledge on the topic. • Describe generally any critical student characteristics or attributes that will affect student learning (other than what you described in the Teaching and Learning Context). - N/a End In Mind - Students will understand what cardiorespiratory endurance and body compostion is, and how it relates to their overall health. - Students will be able to correctly pass and shoot the gator skin ball. Connections Connect your goals and objectives to appropriate Kentucky Core Content, Kentucky Occupational Skill......

Words: 791 - Pages: 4

Premium Essay

Essay Questions

...Essay Questions Kristy Bazzanella Liberty University Essay Questions Assessment is a vital component in the counseling process. Use of both informal and formal assessment methods ensure that clinicians judgments are non-biased, and when utilized correctly aide in formulating of case conceptualizations and treatment plans (Whitson, 2013). The primary purpose of assessments, for the counselor, is to obtain information to effectively counsel clients. According to Whitson (2013), once all information is gained, the counselor, can “either formally or informally, diagnose the client” (p.285). It is critical that the counselor choose assessments that are both reliable and valid. The choice of assessment type and instrument will vary depending on the presenting problem, age, and cognitive and developmental state of client. Assessments will also vary according to settings. For example, the choice of assessment instruments utilized by a school counselor will differ greatly from the assessments utilized in a drug treatment or psychiatric facility. Assessments can have either a negative or positive impact on treatment planning. Counselors who use informal assessment techniques, such as unstructured interviews may find that the information gathered is not reliable and, therefore, prone to error (Whitson, 2013, p.111). Inexperienced counselors who use unstructured interviews have been observed to focus on minor issues and have failed to collect adequate......

Words: 750 - Pages: 3

Premium Essay

Ece 354 Assessment and Intervention During Early Childhood

...ECE 354 Assessment and Intervention During Early Childhood Click Link Below To Buy: http://hwcampus.com/shop/ece-354-assessment-and-intervention-during-early-childhood/ As you have learned throughout this course, assessments are used for many purposes. As professionals working with children, we must look at assessment as a driving force behind planning instruction and developing goals for those children in our care. We must begin to understand the relationship between how children are assessed and how assessment data is used. This is a multi-step process of gathering data, determining goals for instruction, and then implementing those goals into our work with children. For this Final Project, you are asked to do the first two steps of this process. You will develop a partial portfolio for the child you observed and, with that information, you will develop instructional goals for that child. This assignment has three parts: The first part of this assignment requires you to develop a mission statement. Using your completed Assessment Purpose KWL Chart from the Week Five Reflection Journal, create your mission statement outlining: The purpose of assessment Your plan for including assessment when working with children How you can use assessment to document children’s work How you will use children’s interests and ideas when assessing. This statement should also include your position on working with children with developmental delays. This mission......

Words: 674 - Pages: 3

Premium Essay

Psycho-Educational Assessment

...Psycho-Educational Assessment: Principles and Practices Name Institution Psycho-Educational Assessment: Principles and Practices Question A The key objectives of psychological assessment for Jimmy based on the assessment process entail testing using different techniques. This will help in arriving at a hypothesis concerning Jimmy’s behavior. The assessment process for Jimmy may entail conducting of a norm-referenced test. This is a standardized psychological test, which is a task that is conducted under standard conditions. This is a key objective in Jimmy’s assessment process because it will help assess some aspects of Jimmy’s knowledge, personality, or skills. The norm-referenced psychological test is standardized on a defined group, which is known as the norm group. This is scaled to ensure that every person’s score reflects a rank in the norm group (Andrews, Janzen, & Saklofske, 2001, p. 51). The norm-referenced test will be essential for Jimmy’s assessment process because it assesses areas such as intelligence, visual motor skills, and adaptive behavior. Interviews may also be conducted during the assessment process because they help in obtaining valuable information. An examination of Jimmy’s case shows that different individuals will be involved during the process. For example, Jimmy’s parents, his teachers, and other people familiar with him like his grandmother may be interviewed (Andrews, Janzen & Saklofske, 2001, p. 59). The other objective of......

Words: 947 - Pages: 4