Nursing Assessment

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Health Assessment Exam of Head, Neck, Chest, and Lungs
Name Here
Nursing 3020-2 Health Assessment Fall 2013
September 29, 2013

Head and Face: Erect and midline; scalp is freely moveable without lesions, lumps or tenderness. Temporal arteries soft, nontender. Facial expression is appropriate for behavior and mood. Facial structures appear to be symmetrical, with no noted edema, drooping or involuntary movements. Temporomandibular joint movement when palpated appears smooth with opening and closing of the mouth with no noted tenderness or limitations.
Eyes: No tearing; conjunctivae pink without discharge, Sclera white. No lesions. pupils round and react equally to light and accommodation; extraocular movements intact, no lid lag, no nystagmus; peripheral vision intact; corneal light reflex equal bilaterally, cornea, lens, and iris clear; Wears no corrective lenses.
Ears: Auricles in proper alignment, without lesions, masses, or tenderness; canals with small amount of dry cerumen; tympanic membranes gray, translucent, light reflex and bony landmarks present; no perforations present, Responds appropriately to conversation, Whispered words heard bilaterally.
Nose, Mouth, Throat: No flaring of nares, septum midline, patent bilaterally, mucosa pink and moist, or discharge; no frontal or maxillary sinus tenderness with palpation. Buccal mucosa pink and moist, no lesions, 32 teeth in good condition, gums look pink with margins at the teeth tight and well defined, no movement; tongue midline, no lesions; uvula midline with soft palate elevation, tonsils removed as a child; gag reflex intact.
Neck: Trachea midline, no tracheal tug, thyroid and cartilages move with swallowing, thyroid lateral borders non-palpable, no enlargement or nodules noted, lymph nodes non-palpable, carotid pulse palpable with no carotid bruits; full range of motion and appropriate…...

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