Physical Health Assessment of Adult

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.

The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient 's complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained

The head to toe physical assessment is the first step of the nursing process and is a systemic approach of collecting objective (physical) and subjective (mental) data on the patient that will help the nurse formulate nursing diagnoses and plan patient care. It is also used to confirm or question data that was stated in the pt. previous history stated in the charts and to evaluate the effectiveness of the nursing interventions that were carried out on the patient. The main focus of the head-to-toe assessment is to focus on what the patient is currently presenting with; the patient's responses to actual or potential problems.

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Three different measurements were taken before and after the study. They included, pain intensity, disability, and quality of life. Pain was taken using a visual analog scale (VAS) which ranges from 0 to 10; 0 equaling no pain at all and 10 equaling the worst pain ever felt. Disability was taken using the Neck Disability Index (NDI). The NDI consisted of 10 items and were scored using percentages, the higher the percentage the higher the disability. And lastly, quality of life was taken using the Medical Outcome Study Short-Form 36 Health Survey (SF-36). Scores in SF-36 ranged from 0 to 100 and the higher the patients number got, the better quality of life.

Picture opening up a box with over 1000 pieces belonging to a jigsaw puzzle, emptying the contents out on to a tabletop, and then being tasked with putting those pieces together to ultimately create a beautiful picture of the human anatomy. One can imagine the eye for detail, patience and thoroughness that would be required to complete such a task. As with any puzzle it is critical that the wider picture is envisioned at all times, as focusing on only one piece would effectively hinder any progress towards completion.

Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 - S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2

The TM through the rest of the hearing pathway, sounds become electrical impulses analyzed by the brain, hence, the sense of hearing (Jarvis, 2012). The assessment and evaluation of the tympanic membrane is vital in a complete otological screening. The otoscope allows inspection of the ear canal and TM to detect excessive cerumen buildup, inflammation, or perforation of the TM. Hearing loss is done through the use of tuning fork performing Rinne and Weber tests and the audioscope which produces a more accurate and conclusive hearing loss test result (Jarvis, 2012). There are four essential components of the TM to evaluate. The color, appearance of the light reflex or "cone of light", the bony landmarks, and mobility of the TM, most important in children can help determine the existence of a problem. TM inspection of foreign body in the ear, trauma, excessive probing, dermatitis, otitic barotraumas, parotitis, tonsillitis, adenoid problems, sinusitis, pharyngitis, otitis externa, and otitis media can lead to abnormal findings (Bradley, 2007). Inflamed TM indicated by distinct erythema and otalgia or ear pain interfering with sleep or normal activity, otorrhea, and detection of air and fluid level behind it, if left untreated can lead to rupture (Bradley,

Upon finishing the danger, response and circulation components of the primary survey the next step is the assessment and maintenance of a patient’s airway. This is a crucial stage as a clear airway allows for air to move in and out of the lungs (Primary Survey Airway Evaluation, 2015). Patients in particular may have less ability to maintain their airway, including the tongue, or liquids

Detailed exam are extended exams of the affected body area or areas and other organs systems, which requires

A head to toe assessment is the visual and manual inspection of each body part starting at the head and scalp and continuing downward to the feet and toes. These four techniques will be used: Inspection=what can be seen, Palpation=what can be felt, Percussion=what can be heard and Auscultation=what can be heard using a stethoscope. It is very important to perform a complete head to toe assessment on all patients at the beginning of the shift as this information will help determine if the patient is getting worse or starts having any unforeseen problems.

Inspection- Uses vision, smell to observe for normal condition and deviations. It can often reveal more than other techniques. It is used when you first meet the patient and continues throughout the health history and physical examination aspects of assessment.

When physically examining the respiratory system, the nurse will inspect, observe, auscultate, percuss, and palpate. This includes: observing the child’s skin for pallor or cyanosis, noting tachypnea, cough and adventitious lung sounds (wheezing), respirations, and checking the mucosa of the nose and mouth.

Neck: No limitations in movements, no lymphadenopathy, thyromegaly, no carotid bruits audible, and no neck rigidity.

There are certain componenets that are essential to be examined these include; inspection of shape, skin and umbilicus, palpation to check for any tenderness, rigidity or masses, Auscultation to assess the bowel sounds and bruits and percussion.