100% satisfaction guarantee Immediately available after payment Both online and in PDF No strings attached
Previously searched by you
Summary Module11 Documentation of the complete head to toe physical assessment.docx NUR2180 Documentation of the complete head to toe physical assessment Rasmussen University NUR2180 Documentation of the complete head to toe physical assessment The $7.49
Add to cart
Summary Module11 Documentation of the complete head to toe physical assessment.docx NUR2180 Documentation of the complete head to toe physical assessment Rasmussen University NUR2180 Documentation of the complete head to toe physical assessment The
Module11 Documentation of the complete head to toe physical NUR2180 Documentation of the complete head to toe physical assessment Rasmussen University NUR2180 Documentation of the complete head to toe physical assessment The patient is a 35-year-old black African female, height 5'6, ...
module11 documentation of the complete head to toe physical assessmentdocx nur2180 documentation of the complete head to toe physical assessment rasmussen university nur2180 documentatio
Written for
Rasmussen College
RAS
All documents for this subject (301)
1
review
By: jodelinebelval32 • 2 year ago
Seller
Follow
helperatsof1
Reviews received
Content preview
NUR2180
Documentation of the complete head to toe physical assessment
Rasmussen University
NUR2180
Documentation of the complete head to toe physical assessment
The patient is a 35-year-old black African female, height 5'6, weight 232 lb. The patient
is awake, alert, aware of stimuli from the environment and self conscious, respond appropriately
and reasonably to stimuli, and is in a good mood. Her thought process is logical, goal-directed,
coherent, and relevant; it forms complete thoughts. The patient is orientated to person, place, and
time—no signs of distress or anxiety. Posture is erect, and the position is relaxed. The patient
moves with feelings of independence; gait is smooth, rhythmic, and effortless; opposite arm
swing and well-coordinated; person turns smooth; step length about 15 inches from heel to heel.
Able to walk in a straight line heel-to-toe and heel-to-heel fashion and is straight and balanced.
Nobody or breath odor noted. Speech is effortless and shares conversation appropriately. The
pace of conversation is moderate, and the stream is eloquent. Choices of words are effortless and
appropriate to her educational level; the patient completes sentences, occasionally pausing to
think. Patient speech and articulation are clear, and the pattern content is appropriate. Personal
hygiene is appropriate, and the patient is groomed for the occasion. There are no physical
deformities noted.
Skin and Hair
The patient color is fair; skin matches her body and ethnicity; dry, moist, fissures and no
cracked noted. skin is smooth and firm with no roughness. Patient Skin elastic turgor, no
excessive bruising, sluggish or edema noted. Patient Skin is fair; pigment is even and consistent
, with genetic heredity. Patient Vital Signs: T 97.8 degrees Fahrenheit temporal. The anterior and
posterior transverse ratio is about 1:2 medium depth radium, and there is no excess muscle use.
Her respiration rate is about 18. her hair is neat and clean and evenly distributed. There is no
lesion, bumps, parasite, scars, moles, or rash noted.
Nails
The Capillary refill in the upper and lower extremities is less than two seconds bilaterally.
The skin of the upper and lower extremities matches the body and ethnicity; warm, smooth, dry,
and intact—no edema, lesions, or signs of clubbing. Nails' shape and contour are round and
clean. The nail base angle is within the normal range of 160 degrees.
Head and Face
The Head is cephalic; no lesions, bumps, or parasites are found. No masses, deformities, and
tenderness are found. Hair is evenly distributed, s silky, and thick. Smooth and soft, and there
were no indications of it being brittle or thin. The patient has a face that is symmetrical and does
not have any lesions or signs of discolor. The patient had smooth and clean skin, warm, whole,
and tandem with her race. The palpation of her face is inclusive of the patient sinuses located
above and below her eyes, and there were no signs of depressions, masses, or pain depicted. The
Patient Skull is round with a smooth skull contour. Skin is warm and dry. Eyebrows are above
symmetrical eyes and raise easily. Facial expression (CN VII). The patient is able to smile,
frown, show teeth, puff out cheeks, and close eyes tightly, Masseter muscles are tight upon
palpation with patient teeth clinched which assesses the motor function of CN V.
Eyes
The patient's eyelashes and eyebrows are both symmetrical and evenly distributed. Her pupils
were observed with a penlight and were found to be round, constrict to light, had a brusque
reaction, and equal. The patient eyes were tested for accommodation by making the patient to
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller helperatsof1. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $7.49. You're not tied to anything after your purchase.
