Health Assessment
Physical Assessment Documentation Form
Date: __3/3/16
Patient Information Patient Initials | LD | Age | 30 | Sex | Female |
General Survey
Does patient appear to be their stated age? | Yes | Level of consciousness | Alert and Oriented x3 | Skin color | Caucasain | Nutritional status | No malnurishment noted, pt she eats three meals a day | Posture and position | Patient maintains good posture and position | Obvious physical deformities | No physical deformities noted | Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement | no problems with mobility noted, patient ambulates w/o assistance, ROM of joints intact, patient pt able to rotate feet,
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| Describe the purpose of the otoscope | checking ears for buildup and injuries, drainage, etc | Explain the Weber and Rinne tests | Rinne test involves tuning fork to be placed on the mastoid bone, and ask when patient no longer hears the vibration,and checks for air conduction and bone conduction Weber test involves stricking the tunning fork in placing in middle of head and ask what ear the sound is coming from, hearing sound in both ears could be a sign of hearing loss (Stubblefield, 2014) | Nose External nose | External nose skin intact, no lesion noted, smooth skin noted, small pores pt denies c/o, no problems noted | Patency of nostrils | Patency noted in nostrils, no drainage noted | Describe the purpose of the nasal speculum exam | Nasal speculum is used to widen the nasal passage for inspection | Mouth and Throat Lips and buccal mucosa | mucosa moist no problems noted | Teeth and gums | teeth and gums intact | Tongue, hard palate, and soft palate | all moist, intact, no problems noted | Tonsils | Tonsils in place, no redness, or patches noted | Uvula (cranial nerves IX, X) | Uvula intact, no redness or patches noted, no lesion noted | Tongue (cranial nerve XII) | Tongue pink and intact, no white patches or yeast noted | Neck Symmetry, lumps, and pulsations | Symmetry noted in neck, no lumps noted, pulsations present in veins |
PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.
Christianity assumes that our human nature is fundamentally and thoroughly flawed by sin, to the point where a divine miracle of grace is needed to allow us to trust Christ as Savior. Most people in Western cultures, however, do not consider themselves to be sinners and therefore feel no need for a Savior. Comment on this in the light of the detailed accounting rules and regulations intended to prevent investors from being defrauded, and the multi-billion dollar worldwide auditing profession that is intended to add credibility to financial statements.
Using the tuning fork to conduct the Weber and Rinne test, the first thing we noticed is that the weber lateralizes to the right. With the Rinne test, we note that bone conduction is greater than air conduction on the right. This is abnormal since air conduction should be greater than bone conduction. The left demonstrates a normal finding with air conduction greater
Behlke, M., & Lestock, J. J. (2017, July 31). McConnell on Health Care: “It’s Time to Move On”. Retrieved from http://www.ncsl.org/ncsl-in-dc/publications-and-resources/capitol-to-capitol-july-31-2017.aspx#McConnell%20on%20Health%20Care
The Quality and Safety Education for Nurses (QSEN) is an institute dedicated to the quality and safety for patients by helping nurses gain the knowledge, skills, and attitudes (KSAs) to provide patient care (QSEN Institute, 2017). Specimen labeling errors fall under the QSEN competency of safety. The purpose of this paper is to present the current problem with specimen processing and compose a second solution to this problem. The organizations that support my project, the National Safety Patient Foundation (NPSF) and the Institute for Healthcare Improvement (IHI), will be discussed as well. Finally, an overall evaluation of the clinical practice project and preceptor experience will be presented.
In the 1790s members of the industry in both Paris and London were working on inventions to try to mechanise paper-making. In England John Dickenson produced the cylinder machine that was operational by 1809. Although useful for smaller enterprises, this lacked the large scale potential of the machine resulting from the invention of Nicholas-Louis Robert in Paris, which had a more complicated incubation period. The last of the early improvements to this machine were financed by the Fourdrinier brothers in London, and it was after these brothers that the machine was named. The Fourdrinier could produce paper of virtually any size for the very first time, limited only by the width of the continuous wire mesh upon which the paper was made.
Childhood obesity is increasing worldwide. Experts estimate that 1 in 5 kids between the ages of 6 and 17 are overweight. That means that as they get older they will be more at risk for diabetes, high blood pressure, and heart related diseases. Things that we used to associate with older people are now affecting younger and younger children. There are many reasons for this rise in obesity and this paper will look at a few of them. My goal is to show a correlation between what children are doing and how it affects their chances of being obese. My data comes from the Centers for Disease Control (CDC) website. They sent a survey to schools in all
The primary assessment of this patient is the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. According to the ABCDE approach, it is crucial to check the airway first to see if the airway is patent. Then, check the patient’s breathing. Determining the respiratory rate, inspecting movement of the chest wall, measuring pulse oximeter and using the stethoscope to auscultate the lung sounds are the possible way to check if the breathing of the patient is sufficient (Thim et al., 2012). Next, check the circulation. Skin changes, such as check the colour and sweating, relate to the circulatory problems. Also, heart auscultation, blood pressure measuring and electrocardiography monitoring should be involved in this procedure (Thim et al., 2012). When measure the blood pressure, using the AVPU score (A for ‘alert’, V for ‘reacting to vocal stimuli’, P for ‘reacting to pain’, U for ‘unconscious’) to assess the consciousness, which is for the disability part. Moreover,
No known allergies, no sinus, tenderness, no epistaxis, no bleeding gums, patient has partial dentures, one dental carrier noted, tongue is slightly coated, no swelling, lumps or tenderness noted in throat,
Sustainability is regarded as a goal of any business. The accounting framework, to support sustainability goal is called as the triple bottom line (TBL).It focus on performance of an organization with the interrelated dimensions of profits, people and the planet.