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Complete Physical Assessment

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| 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, Skin noted to be cool to touch
Vision observed without correction
Physical Examination
Head and Face 1. Scalp is intact – no lesions, lumps scaling, parasites or tenderness. Hair is noted to be closely shaved. Cranium is symmetrical in appearance. 2. CN VII, V (Trigeminal, Facial) Intact – Jaw muscles equally strong both sides, able to clench teeth, lift eyebrows, puff cheeks, and show teeth without difficutly 3. Temporomandibular joint is strong against resistance 4. Maxillary Sinuses frontal sinuses
Neck
1. Neck is midline and symmetrical in appearance. Supple without lumps or pulsations on palpation. 2. Trachea is midline 3. Cervical lymph nodes without lymphadenopathy 4. Carotid pulses 2+ and equally bilaterally, no buits on auscultation 5. Thyroid Gland non palpable 6. Jugular venous – no JVD evident 7. AROM without limitation and muscle strength intact 8. CN XI (Spinal Accessory) Able to resist rotate head either direction against resistance and shrug shoulders against resistance without difficulty
Eyes
1. CN III, IV, VI (Oculomotor, Trochlear, and Abducens) Intact - Visual field full by confrontation. 2. External Structures: normal alignment and symmetry evident. No ptosis, lid lag, discharge or crusting noted. 3. Conjuctivae; clear and Pink Sclerae: White Corneas: no irregularities noted 4. Pupils: round, equal and reactive to light with accommodation 5. Extraocular muscles able to tract objects without difficulty
Ears
1. External Ear intact without masses, lesions tenderness or discharge evident, non tender to palpation. 2. Otoscope: ear canal with slight cerumen present, without redness, swelling lesions foreign body or discharge, Tympanic membrane pearly gray in color with light reflex and no perforations. 3. CN VIII (Acoustic) , voice test responds to whispered words at approximately 2 feet without difficulty bilaterally. Rinne and Weber Test not completed during this assessment.
Nose
1. External nose symmetric without deformity or lesions, nares are patent 2. Speculum: nasal mucosa: pink no discharge, lesions or polyps. septum without deviation or perforation. 3. CN I (Olfactory) Intact – Able to identify smell of lemon, Sniff test equal bilaterally.
Mouth and Throat 1. Lips and buccal mucosa pink, moist without lesions. 2. Teeth are all present straight and in good repair. 3. Tongue smooth pink without lesions protrudes in midline, no tremor. 4. Hard/soft palate intact, pink and moist. 5. Tonsils are present 1+ 6. CN IX, X, XII (Glossopharyngeal, Vagua, and Hypoglossal) Intact- Uvula rises on phonation, Tongue without tremors and is midline, Gag reflex present
Chest and Lungs 1. Thoracic cage configuration equal and symmetric expansion 2. Tactile fremitus equal bilaterally. No Lumps or tenderness noted 3. Spinous processes: Normal spinal curvature evident. 4. Percussion over lung fields resonant; diaphragmic excursion approximated at 5cm and equal bilaterally 5. Breath Sounds clear without adventitious sounds all lobes
Heart
1. Precordium;– PMI not visible, palpable in 5th ICS, MCL normal size, 2. Apical Pulse, Apical rate and rhythm: Ausculated to have regular rate and rhythm 3. Heart Sounds S1 heard best at apex, S2 heard best at base, no extra sounds or murmurs identified.
Abdomen
1. Contour, symmetry flat without scars or lesions noted, umbilicus is midline and inverted 2. Bowel Sounds Active x 4 quadrants without bruits noted 3. Vascular Sounds not ausculated. 4. Light and deep palpation without tenderness, mass or guarding evidenced. 5. Palpation of liver – edge not palpated, percussion approximated at 8 cm in Right mid clavicular line. Spleen non palpable.
Upper Extremities: 1. Upper Extremities are symmetrical in appearance without scaring, lesions or tenderness evident. Skin is dry and cool to touch; nails are manicured, capillary refill within 2 seconds noted. 2. Pulses: Radial 2+ equal Brachial pulses 2+ equal. AROM both extremities, smooth movement without crepitus or tenderness. Muscle strength able to maintain flexion against resistance. 3. Allen’s Test to Right wrist completed with return of blood flow within 3 sec.
Lower Extremities 1. Lower Extremities symmetrical in appearance without lesions, or tenderness evident. Skin is dry to touch, with hair distribution equal. 2. Pulses: Femoral pulse ( located in groin area not palpated) Popliteal 2+ Equal , postior tibal 2+ equal, dorsalis pedis 2+ equal 3. AROM to hips, knees and feet. Muscle strength – able to hold flexion against resistance.

Neurologic 1. Sensation, face, arms, hands, legs and feet intact all fields – able to accurately identify sharp vs soft sensations to all fields tested. 2. Sterognosis: able to identify key provided. 3. Graphesthesia: able to identify number three written on palm of each hand 4. Cerebellar: fingers to thumb rapidly and smoothly without difficulty. 5. Able to Run heel down shin (neuro) both extremities. 6. Romberg’s sign: negative 7. Deep tendon reflexes: Biceps 2+ , Triceps 2+, Brachioradialis 2+, Patellar 2+, Achilles 2+, Plantar reflex 2+

Summary
Patient is a 40 year old African American Male patient without any current heath concerns identified this assessment period. Potential teaching needs based on his age and genetic factors include dietary concerns for diabetes and hypertension.

Nursing Diagnosis’s
#1 Potential for Knowledge deficient: community resources, nutrition, and wellness related to unfamiliarity with information resources and lack of exposure as evidenced by verbalized deficiency in knowledge (pterry, 2009)
Goal:
Client will demonstrate knowledge of community resources via verbalization
Interventions:
Asses the client’s ability, readiness to learn and previous knowledge r/t health preservation, medication management, disease states and community resources. Learning best occurs when learners are motivated and when instruction is tailored to the client’s cognitive ability
Assess personal context and meaning of illness including perceived changes in lifestyle, financial concerns and impact on culture. Providing interventions that incorporate personal perspectives and meaning of illness results in improved symptom management and client satisfaction (Hornsten, Lundman, Stenlund, & Sandstrom, 2005). Provide information to support self-efficacy, self-regulation and self-management by focusing on problem solving and decision making. Educational programs based on empowerment have demonstrated effectiveness (Deakin, McShane, Cade, & Williams, 2005).
· Tailor the delivery of instruction to the client’s cognitive level by using visual aids (medication chart, brochures on Oak & Acorn and Elderserve’s Companion Program) and accessible word choices. Clients with lower literacy benefit from well-tailored materials (DeWalt, et al., 2004).
· Evaluate learning outcomes using patient verbalizations. Evaluation serves as an assessment of the effectiveness of care and allows opportunity for adjustments to the plan of care (Ackley & Ladwig, [Year]).

#2 Potential for Knowledge deficit related to lack of information about the disease process and self care (Nanda Nursing Interventions , 2012)
Goal:
Patients can express their knowledge and skills for the management of early prevention for hypertension.
Interventions:
Provide educational information about the disease process that is tailored to the patient’s educational level
Describe to the patient how blood pressure works in the body, and the importance of why we need to control it.
Provide multiple opportunities for the patient to return for question and answer sessions
Explain to the patient the importance of sodium and dietary factors with hypertension
Discuss the need to maintain a healthy stable weight.
Offer the patient the opportunity to attend nutritional counseling in order to understand dietary constraints
Educate the patient on the need to monitor his blood pressure at least every two weeks or more frequently if he notices that it starts to become higher than 140/80 and report to his physician.
Bibliography
Jarvis, C. (2012). Physcial Examination & Health Assessment. St. louis, MO: Elsevier Inc.
Nanda Nursing Interventions . (2012, May 4). Retrieved from nanda - Nursing interventions: http://nanda-nursinginterventions.blogspot.com/2012/05/4-nursing-diagnosis-interventions-for.html pterry. (2009, March 17). Free Nursing Care Plan Examples . Retrieved from Nursing Resources: http://www.pterrywave.com/nursing/care%20plans/Nursing%20Care%20Plans%20TOC.aspx…...

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