NSG 120 Stratford University Nursing Assessment Template

User Generated

Wbnaohawr

Health Medical

NSG 120

Stratford University

NSG

Description

Instructions

-Please use the information on the template already filled out to help you fill out the two blank Templates provided below. Template #2. and Template #3 is to generate a thorough problem list based on Diagnostic Reasoning. The list should be all actual and potential problems. Please include at least one reference in each Template

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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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Explanation & Answer

Attached. Please let me know if you have any questions or need revisions.

NURSING ASSESSMENT PART 3

Name: S.C.

Date: 25th January 2021

Continue your Nursing Health Assessment

HEENT (head, ears, eyes, nose and throat)


Inspect head, eyes, ears, nose for size, shape, symmetry.
The head is symmetrical, size appropriate for her age. The eyes are of normal size, shape,
and symmetrical. The ears are bilaterally intact and pearly shaped.



Palpate head, hair, face and sinuses for any deformities, tenderness, masses.
On palpation, there are no tenderness or trauma or masses. The hair is black, with no
signs of hair loss. There is no tenderness on the maxillary sinuses. The face is smooth,
with no pimples or rashes; it is symmetrical and has no trauma signs.



Assess eyes with penlight for pupil size, reactivity & accommodation. 6 cardinal
fields of gaze. Symmetrical?
The eyes are symmetrical and have no abnormality with no swelling on the eyelids, no
jaundice, and conjunctiva is pink. The pupil size is normal, with a size of 4.4 mm and
equal and clear. The pupil dilates when distant objects are observed under dim light by
the patient and constricts under shining light on reactivity. On accommodation, the pupils
constrict and move equally to cross when the patient looks at distant objects the allow the
patient to stare at the penlight. To assess the six cardinal fields of gaze, a penlight was...


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