Name: Joan Bunje
Date: 01/17/2021
Nursing Physical Assessment Part 1
Health Assessment is a skill that must be practiced frequently and continue throughout
your nursing career. Practice your health assessment skills on someone outside of class.
You may use a family member or another classmate. Do not give their name or identifying
information. Use your text as well as information on the Moodle site to help. Describe
each area thoroughly. Please state what you see. Please type using the following format.
Upload on the Moodle class site by the due date. See Rubric on last page.
Background information (this is not a complete nursing history. Only basic information
that may affect be noticed during the physical assessment).
•
Patient Information: initials, age, sex, race. History of chronic illness,
surgeries, allergies and is the patient on any medications. Give information
about medications. What are they for, dosage, time given? How long have they
been on them? Any problems with the medications?
Patient Initial: C.M
Age: 52
Sex: Female
Race: African American
C.S has no history of chronic illness, no surgeries of any kind mention, no
allergies and the patient take two medications daily which are: Hydrochlorothiazide 25mg
one tablet daily which patient has been taking for about eight years due to High Blood
Pressure. Patient is also taking Losartan 50mg, one tablet daily and it is also blood pressure
medication and it has been a year since she was placed on this medication. Patient has no
problems taking this medication and the medication gives her no problems as verbalized.
1
Preparing and Initiating Health Assessment.: Hello Ms. C.S I am Joan and am going to
be your nurse today. Is that okay with you and she says yes. Let me wash my hands. Can
you please tell me your name, date of birth and where you are? The patients respond
appropriately, and I also double check to make sure all information she has given is correct.
Ms. C. S I will be doing a physical health assessment with you, is that okay with you.
Patients says yes.
•
Inspect Environment: safety, emergency, privacy: The environment is free of
clutter. Patient is alert and oriented times four, has no fall risks, lives on the third
floor of her house, and have no difficulty going up and down the stairs. Patient’s
door is closed to provide her privacy. There are side rails on the stairway for use
should in case of difficulty going up and down the stair.
•
Assess BP, Heart Rate, Respiratory Rate, Temperature, and Pain and
verbalizes findings: Patient vital signs are as follows:
BP= 134/82 mmHg
Heart Rate= 82 beats/ minute.
Respiratory Rate= 18./minute
Temperature= 97.8 degrees Fahrenheit
No pain (Patient verbalizes no pain)
•
Describe how you would appropriately position patient for comfort, safety,
and privacy throughout assessment: Wash your hands, Position patient on an
upright position on a comfortable chair to promote comfort and relaxation Ensure
the environment is free of any distracting items or clutter from the floor, reduce
extra noise and close the door for privacy.
2
General Appearance and Mental Status: The patient is alert and oriented, has
appropriate mental status (Patient can state her name, date of birth, where is and answering
all questions with no difficulty). Patient appearance is within the acceptable range.
Assess apparent general state of health, affect and mood—Are they smiling, unhappy
appearing, do they appear anxious or angry? The Patient is very happy and smiling, no
anger or anxiety is expressed or noted, appears appropriate for her sated age, well dressed
and general affect and mood are very appropriate.
•
Speech pace and clarity, responds appropriately? Describe: The patient speaks
clearly; speech pace is neither too fast nor too slow. There is proper articulation of
sentences and responds appropriately.
•
Posture-Are they able to sit erect, do they have any obvious problems with
mobility? Please Describe: The patient can sit in an erect posture without any
assistance. Patient displays no problems with mobility and can walk without
assistance.
•
Personal hygiene (odors, cleanliness): The patient’s hygiene is appropriate;
Patient has no body or mouth odors, nails and hair are very clean and well
maintained and her hair looks appropriate for her stated race.
3
•
Assess alertness, orientation to person, place, & time—ask their name, where are
they and the time of day. Patient is alert and oriented times four and can state her
name, date of birthplace, where she is and time of the day.
Please do not give name or personal identifying information of the person you are
examining. Use initials.
CATAGORY
Exemplary
Competent
Developing
Competency
Not
competent
Content
Content demonstrates what has
been learned in the course or
readings. All components of
the criterion is addressed in a
comprehensive and
thorough manner 5 pt.
Is clear, concise, and easy to
understand. Uses terminology
appropriately.
2 pt.
Content
addressed
but one or two
areas needed.
more
detail.
Maximum 3pt.
Some proofreading
errors or an incorrect
term
1 pt
Content
is superficial
and
not
well
developed.
1 pt.
Unclear or
incorrect
language
0 pt.
Did
not
address.
or
very
little
content.
0 pt.
Language
4
NURSING HEALTH ASSESSMENT
PART 2
Name: ____________________________
Date: _____________________________
Continue your Nursing Health Assessment
Neurological Assessment – ask appropriate questions (verbalize results)
•
Assess alertness, orientation to person, place, & time—ask their name, where are they and the
time of day.
Integumentary
•
Inspect skin throughout assessment: notes temperature, integrity, & areas of redness, turgor
•
Inspect nails for cleanliness, color, shape, opacity
Musculoskeletal Assessment (ask appropriate questions, verbalize findings, compare right to left in all
assessments).
•
Inspect extremities for ease of movement & need for assistance
1
•
Perform range of motion on upper and lower extremities (passive & active)
•
Assess muscle strength neck, shoulder, upper & lower extremities, Compares right to left
CATAGORY
Exemplary
Competent
Developing
Competency
Not
competent
Content
Content demonstrates what has
been learned in the course or
readings. All components of
Content
Content
addressed
the criterion are addressed in a
comprehensive and
but one or two
is superficial
and
Did not
address
areas needed
not well
developed.
thorough manner 5 pt.
more detail.
Maximum 3pt.
1 pt.
Is clear, concise, and easy to
understand. Uses terminology
appropriately.
Some proofreading
errors or an incorrect
terms
Unclear or
incorrect
language
2 pt.
1 pt
0 pt.
Language
or very
little
content.
0 pt.
2
NURSING ASSESSMENT PART 3
Name: ____________________________
Date: _____________________________
Continue your Nursing Health Assessment
HEENT (head, ears, eyes, nose and throat)
•
Inspect head, eyes, ears, nose for size, shape, symmetry.
•
Palpate head, hair, face and sinuses for any deformities, tenderness, masses.
•
Assess eyes with penlight for pupil size, reactivity & accommodation. 6 cardinal fields of gaze.
Symmetrical?
•
Assess hearing: vocal and soft sounds
1
•
Assess oral cavity: dentures? Difficulty swallowing, condition of teeth, mucous membranes,
tongue, hard and soft palette, and posterior pharynx.
•
Inspect neck for trachea position and presence of lymph nodes
Respiratory Assessment
•
Inspect anterior and posterior chest wall for use of accessory muscles when breathing
•
Inspect for rhythm and ease of breathing
•
Palpate for chest expansion and fremitis
•
Auscultate anterior, lateral, and posterior chest wall at all assessment sites and verbalize
appropriate location of sounds: adventitious sounds, bronchial, bronchovesicular and vesicular
breath sounds. (listens to full inspiration and expiration at each site and compares side to side)
2
CATAGORY
Exemplary
Competent
Developing
Competency
Not
competent
Content
Content demonstrates what has
been learned in the course or
readings. All components of
Content
Content
addressed
the criterion are addressed in a
comprehensive and
but one or two
is superficial
and
Did not
address
areas needed
not well
developed.
thorough manner 5 pt.
more detail.
Maximum 3pt.
1 pt.
Is clear, concise, and easy to
understand. Uses terminology
appropriately.
Some proofreading
errors or an incorrect
terms
Unclear or
incorrect
language
2 pt.
1 pt
0 pt.
Language
or very
little
content.
0 pt.
3
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