Physical Assesment WORD document PDF

Preview

Summary

STudy this and make a separate word document with your physical assessment lines to practice for the video project...

Description

Name Gricelda Vasquez

Date:11/02/2021

Client’s initials A.D

Adaptedfrom ATI Skills Modules Checklist for Physical Assessment (Adult)-N190 2021

Client’s initials A.D

System

Date 11/02/2021

Assessment

Initial Biographical Client’s initials, address, phone Data Age and Date of birth Gender and race

History

A.D, 123 Donald Duck Lane, Disneyland, Ca 324-456-6789 24 years old, 06/08/1997 Males/ Caucasian

Marital status Religion

single Atheist

Occupation

Full time student

Source of information and reliability of source

Client/ reliable source

Reason for seeking care/ present illness Health beliefs (ex: western medicine, holistic) Health patterns (nutrition, exercise, stress, sleep)

Sleep deprivation

Health goals (one measurable goal)

To sleep 8 hours a night by setting a sleep routine 1 hour before bed and not taking any naps during the day No medications

Medications (prescribed and over the counter) Allergies (medication, food, and environment) Immunizations Past History (including dates)

Documentation of Findings

Western medicine Nutrition: vegan, exercise 6 days/week for 45 mins sessions of cardio and weightlifting, stress:4/10, sleep: 3 hours per night

Medical history

Meds: none, Food: no, Environment: Pollen and fine animal hair All up to date on immunizations Covid: yes, flu: yes, HPV: yes none

Surgical history

none

Hospitalizations

none

Injuries

none

Blood transfusions or blood conditions Mental health/psychiatric history

none

Family history

Family history (include three generations)

Maternal Grandmother: Breast cancer Maternal: anxiety Paternal: no history

Social history

Use of tobacco, alcohol, drugs, caffeine

Tobacco: none, alcohol: 1-2 drinks a year, drugs: none, caffeine: 2 cups of coffee a day.

General Survey (Observations)

Physical Appearance

Nourished, young, well groomed. skin color is pink and white. Tall and slender LOC x3, patient seems up and happy and talkative. Patience seems calm and speech is clear and annunciated well

Generalized anxiety

Mental Status

No issues with balance or gait detected and no assistive device needed No body order, cleanliness appearance, makes eye contact and is responsive to all questions.

Neurological status (gait, balance) Measure Vital Signs Behavior

98.7 F

Temperature (document route) Pulse (rate and rhythm)

Label beats/ min

52 beats per min, steady/regular

Respiratory Rate (rate and rhythm)

Breaths/ min

16 breaths per min symmetrical

Blood pressure

mmHg

Height and Weight

72 inches, 200 lbs.

System

Skin, hair, and nails (Subjective data)

Assessment

Findings

Review of Systems (Skin, hair, and nails). Using your textbook as a guide, collect subjective data on skin, hair, and nails. Write comprehensive sentences summarizing your findings. OLDCART-

Current symptoms (OLDCART/ICE) Problem:_________________ (Oldcart is required each week)

Family history of skin, hair, and nails

Physical Exam: skin, hair, and nails (Objective data)

Inspect head and scalp for color, hair distribution, and lesions Inspect for infestations Inspect and palpate skin for texture, moisture, and temperature. Avoid no Pinch skin fold under clavicle to tenting check skin turgor. Note body-hair distribution on legs. Assess any wounds or lesions. Inspect for edema. Inspect nails of feet and hands. Check for clubbing (nail angle). Check capillary refill. Inspect skin on posterior surfaces, check for blanching.

In degrees In seconds

ICE-

System Head, face, and neck (Subjective data)

Assessment Review of Systems (Head, face, and neck). Using your textbook as a guide, collect subjective data on head, face, and neck. Write comprehensive sentences summarizing your findings. Current symptoms (OLDCART/ICE) Problem: (Oldcart is required each week)

Family History of head, face, and neck

Physical Exam: head, face, and neck (Objective data)

Inspect head for size and shape, placement of features Examine face for symmetry. Observe skin of face.

Palpate skull and hair. Palpate temporal arteries bilaterally Test cranial nerve V by asking patient to bite down then close his eyes and report light touch. Examine neck and carotid arteries. Inspect and palpate trachea Palpate and auscultate thyroid. Check range of neck motion. Observe for jugulovenous distention.

Findings

OLDCART-

ICE-

Locate and palpate lymph nodes (list each by name)

System Eyes and Vison (Subjective data)

Assessment Review of Systems (Eyes). Using your textbook as a guide, collect subjective data on eyes and vision. Write comprehensive sentences summarizing your findings. Current symptoms (OLDCART/ICE) Problem: (Oldcart is required each week)

Findings Eyes are symmetrical.

OLDCART-

Family history of eye

Physical Exam: Eyes (Objective data)

Vision Testing: Test distant vision using Snellen chart. Corrected? Test near vision using Rosenbaum chart. Corneal light reflex. Six Cardinal Fields of Gaze. Assess for nystagmus. Cover/Uncover test. Assess for strabismus. Test peripheral vision (confrontation). Assess pupils for shape, reaction to light, and accommodation. Opthalmoscope exam: Red reflex Inspect and palpate eyes, eyebrows, and eyelashes

XXXXXXXXXX

ICE-

Retract lower lids to note palpebral conjunctivae. (not done in classdocument your normal findings)

System Ears, Nose, Mouth, and Throat (Subjective data)

Assessment Review of Systems (Ears, Nose, Mouth, and Throat). Using your textbook as a guide, collect subjective data on ears, nose, mouth, and throat. Write comprehensive sentences summarizing your findings. Current symptoms (OLDCART/ICE) Problem:_________________ (Oldcart is required each week)

Family history of ears, mouth, nose, and throat

Physical Exam: Ears, Nose, Mouth, and Throat (Objective data)

Findings

Inspect ears for shape, placement, and discharge. Check for tenderness by palpating pinna, tragus, and mastoid process bilaterally Insert otoscope to inspect ear canals and tympanic membrane (note the cone of light). Test balance (Romberg test) Test hearing (Rinne, Weber, Whisper tests) Assess nose: septum, discharge, nasal mucosa. Test Cranial Nerve I by identifying scents

OLDCART-

ICE-

Palpate, percuss, and transilluminate sinuses Mouth and tonsils: inspect teeth, salivary glands, and frenulum. Assess oral mucosa, gums, and tonsils. Test ability to swallow. Check for midline tongue protrusion. System Respiratory (Subjective data)

Physical Exam: Respiratory (Objective data)

Findings Review of Systems (Respiratory). Using your textbook as a guide, collect subjective data on respiratory. Write a comprehensive paragraph summarizing your findings. Current symptoms (OLDCART/ICE) Problem:___Sleep apnea_____________ (Oldcart is required each week)

Patient has sleep apnea since 2019 and uses CPap machine. PT breathes through his nose No smoking, No environmental / workplace factors affecting breathing. PT exercises 1 day a week for 30 mins. No HX of breathing problems on both maternal and paternal side. No problems with breathing during a flight of stairs. Patients switches from side to side to sleep and uses one tempurpedic .

Family history of respiratory

No family HX

General inspection: skin color and tone, posture, symmetry, shape of thorax

Skin color is pink and warm to touch. Clavicle are even bilateral and chest is 2:1 in shape.

Count respiratory rate, assess rhythm and pattern Assess nails (color, shape)

24 breath per minute, even and smooth.

Assess posterior then anterior thorax: Palpate thorax (temperature, tenderness, masses)

XXXXXXXXXXXX

Assess respiratory expansion

Bilaterally smooth and even

Assess tactile fremitus

Strong

Percuss (using indirect percussion)

O- 2019

I- if CPAP machine is not used then pt is groggy, and affects mood and has headaches. L- chest/ lungs C-pt copes well when CPAP machine is used which is 90% of the time D- only during naps/ sleep E-pt states that it makes him sad and insecure C- uses cpap A-if he doesn’t use his CPAP machine R- Using your CPAP machine T- None

pink

Auscultate for tracheal, bronchial, bronchovesicular, and vesicular lung sounds (document I:E ratio and sound heard) Auscultate for adventitious sounds

System Cardiovascular

(Subjective data)

Assessment Review of Systems (Cardiovascular). Using your textbook as a guide, collect subjective data on cardiovascular. Write a comprehensive paragraph summarizing your findings. Current symptoms (OLDCART/ICE) Problem: ________Numbing and tingling on left ring finger and pinky__________ (Oldcart is required each week) Family history of cardiovascular

Physical Exam: Cardiovascul ar (Objective data)

Trachea sound is II Bronchovesicular I=E Vesicular I>E No adventitious sounds

Findings Diet: high fat, high protein. Activity: 1x a week, smoke: no, alcohol: no; no SOB, chest pain, Numbing and tingling on left hand but on ring finger and pinky only. Nothing seems to make it worse or better and pt has not seeked any treatment. PT has no hx or surgeries or cardiovascular disease. O- Does not remember I-no impact L- Left ring finger and pinky C- stretching D- comes and goes E- nervous, scared it might be something severe. C-numb and tingling A- nothing R-nothing T-has not seeked treatment Hx of hypertension and diabetes on both maternal and paternal side

Inspect and palpate skin (color, temperature, and moisture) Inspect five cardiac landmarks Palpate five cardiac landmarks, locating point of maximal impulse Auscultate five cardiac landmarks using diaphragm of stethoscope (note rate, rhythm, S1:S2 ratio)

Use bell of stethoscope to assess for murmurs Percuss heart to determine borders Assess for JVD

APETM-

Auscultate carotid arteries bilaterally Auscultate First before using bell of stethoscope palpating Palpate carotid arteries bilaterally Assess for pulse deficit Palpate (size) and auscultate abdominal aorta for bruits

One at a time

System Peripheral Vascular (Subjective data)

Assessment Review of Systems (peripheral vascular). Using your textbook as a guide, collect subjective data on peripheral vascular. Write a comprehensive paragraph summarizing your findings. Current symptoms (OLDCART/ICE) Problem:_______________ OLDcart is required each week in your workbook.

Findings

OLDCART-

Family history of peripheral vascular

Physical Exam: Peripheral Vascular (Objective data)

Inspect and palpate upperextremities

Assess finger nails (shape, capillary refill) Assess for edema Assess lymph nodes Inspect and palpate lower extremities Assess toe nails (cap refill) Assess for edema Assess/test for varicose veins (Manual compression test or Trendelenberg test) Palpate all pulses (document rate, rhythm, and amplitude bilaterally)

Perform Allen test

Carotid: Brachial: Radial: Femoral: Popliteal: Dorsalis pedis: Posterior tibial:

ICE-

System Abdomen (Subjective data)

Assessment Review of Systems (Abdomen). Using your textbook as a guide, collect subjective data on abdomen. Write a comprehensive paragraph summarizing your findings.

Pt states that he eats take-out since starting nursing school, PT has gained weight since his last physical exam a year ago. Pt has 2-3 BS a day that are light brown and solid but not too solid. No bloating or increased gas production. Pt is lactose intolerant, so he has to limit his dairy. Never had a dx of abdominal issues. NO hx of abdominal infections.

Current symptoms (OLDCART/ICE) Problem:__Lactose intolerant____

O- 11 yrs of age I-have to be near a toilet at all times L- stomach and abdomen as a whole C- using the restroom and resting D- mins to hours E-exhausted C-abdominal pain and discomfort, diarrhea A-dairy and spicy foods R-not ingesting dairy and spicy foods T-pepto bismol

Family history of abdomen

Brother has hx IBS for a year.

Collect 24 hour dietary intake (include portion size and fluid intake)

Physical Exam: Abdomen (Objective data)

Observe contour using landmarks. Note symmetry, color, veins, lesions, scars, umbilicus, and movement Assess for abdominal pulsations.

Height: Weight: BMI:

Findings

Auscultate bowel sounds in four quadrants, starting in RLQ (document rate and sound heard). Using bell of stethoscope, auscultate abdominal aorta for bruits. Percuss four abdominal quadrants. Palpate four abdominal quadrants. (light and deep) Check for rebound tenderness (Blumberg’s sign)

Percuss for liver border at MCL and MSL Assess Murphy’s sign on liver Percussion (blunt) costovertebralangle tenderness-urinary

System Musculoskeletal

(Subjective data)

Assessment

Findings

Review of Systems (musculoskeletal). Using your textbook as a guide, collect subjective data on musculoskeletal. Write a comprehensive paragraph summarizing your findings. Current symptoms (OLDCART/ICE) Problem:___________________

OLDCART-

Family history of Musculoskeletal

Physical Exam: Musculoskeletal

(Objective data)

General survey (overall appearance, posture, gait/balance, skeletal and muscle development. Inspect, palpate, assess range of motion and muscle strength (bilaterally) to each joint: TMJ Spine Shoulders

Elbows Wrists and fingers Hips

XXXXXXXXXX

ICE-

Knees Ankles, feet, and toes

System Neurologic (Subjective data)

Assessment Review of Systems (Neurologic). Using your textbook as a guide, collect subjective data on neurologic. Write a comprehensive paragraph summarizing your findings. Current symptoms (OLDCART/ICE) Problem:____________________

Findings

OLDCART-

ICE-

Family history of neurologic (did you document 3 generations?)

Physical Exam: Neurologic (mental status, cranial nerves, sensory /motor, and reflexes) (Objective data)

Assess mental status (LOC, dress, behavior, mood, memory). Complete mini-mental status exam Test Cranial Nerves

Sensory testing (temperature, touch, sharp vs dull, two point discrimination) Assess stereognosis Assess graphesthesia

I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Spinal Accessory XII Hypoglossal

Motor testing (Romberg, gait, finger to nose, alternating rapid action). Assess deep tendon reflexes (document rating and movement bilaterally)

Assess Babinski reflex

Biceps: Triceps: Brachialradialis: Patellar: Achilles:...