...| 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 assessment...
Words: 1469 - Pages: 6
...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 appears...
Words: 324 - Pages: 2
...Physical activity self-assessment 1.On average, how many days per week are you physically active?How many hours per week are you physically active? On average, I am physically active about five times a week. I am physically active for an average of 7.25 hours a week. 2.What types of activities are you performing the most? From my analysis Daily Physical Activity calendar, I noted that I play team sports more than individual sports. I play more hockey than all of the other physical activities on the calendar combined. In fact, I play for the school team as well as for the Pee Wee AA Elites. I enjoy the social interaction with the other players on my hockey teams. I have met many nice people. I prefer team sports more than individual sports...
Words: 430 - 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...
Words: 287 - Pages: 2
...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 open...
Words: 541 - Pages: 3
...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
...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 resolution...
Words: 263 - Pages: 2
...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
...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 (dull...
Words: 14995 - Pages: 60
...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 normal...
Words: 843 - Pages: 4
...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 respirations...
Words: 5413 - Pages: 22
...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 approach...
Words: 824 - Pages: 4
...Introduction` Organizations today compete fiercely in the war for recruiting and hiring the best talent available in the market, investing enormous amount of money, time and other resources in advertising and recruiting strategies. Organisations recognize that one of the most important resources - if not the most important - is human resources. Organisations use several ways, methods and tools to select and hire human resources. But it is now a proven fact that organisations using scientifically proven assessment tools to make selection decisions, show significant increase in productivity, increased cost savings and decrease in attrition and other critical organizational problems. Most organizations use what is commonly known in Management circles as a funneling approach to selection, where more informal tools and procedures are used initially to reduce the pool of candidates to a manageable number of individuals who are then be put through a more extensive assessment process. Common initial screening devices include resumes, application blanks and reference checks, which are generally used to identify and exclude those who do not meet the requirement of the orgnisation, from further consideration. Another initial screening device is the informal meeting or phone interview, which is often used to allow organizational members direct interaction with potential candidates who will perform effectively, achieve results and make important contributions on the...
Words: 3167 - Pages: 13
...SHRM FOUNDATION’S EFFECTIVE PRACTICE GUIDELINES Selection Assessment Methods A guide to implementing formal assessments to build a high-quality workforce Elaine D. Pulakos SHRM FOUNDATION’S EFFECTIVE PRACTICE GUIDELINES Selection Assessment Methods A guide to implementing formal assessments to build a high-quality workforce Elaine D. Pulakos This publication is designed to provide accurate and authoritative information regarding the subject matter covered. Neither the publisher nor the author is engaged in rendering legal or other professional service. If legal advice or other expert assistance is required, the services of a competent, licensed professional should be sought. Any federal and state laws discussed in this book are subject to frequent revision and interpretation by amendments or judicial revisions that may significantly affect employer or employee rights and obligations. Readers are encouraged to seek legal counsel regarding specific policies and practices in their organizations. This book is published by the SHRM Foundation, an affiliate of the Society for Human Resource Management (SHRM©). The interpretations, conclusions and recommendations in this book are those of the author and do not necessarily represent those of the SHRM Foundation. ©2005 SHRM Foundation. All rights reserved. Printed in the United States of America. This publication may not be reproduced, stored in a retrieval system or transmitted in whole or in part, in...
Words: 20431 - Pages: 82
...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 Standards...
Words: 791 - Pages: 4
