Nursing Assessment

In: Other Topics

Submitted By mkstaska
Words 363
Pages 2
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…...

Similar Documents

Family Nursing Diagnosis/Assessment

...Family Nursing Diagnosis and Assessment September 3, 2012 University of Phoenix Nursing 405 Ginger Witherington After spending time with my family and assessing their daily activities it is very apparent that they all need help coping and finding a solution to the growing problem within their home. By using the Friedman Family Assessment as a guideline to identify the structural framework of this particular family, nursing diagnosis and interventions can be drawn as a guide to help with the healing process of their family. According to Healthy People 2020, one particular goal is the “Reduce substance abuse to protect the health, safety, and quality of life for all, especially children”. (Healthy People, 2020). Alcohol and drug abuse is a pattern that is accompanied by failure to fulfill responsibilities such as work and family and can have harmful personal, physical and emotional consequences that lead to the downfall of family. The population that I believe most effected by substance abuse in the family is the children. When there is long term abuse, complications that arise are violence, domestic abuse and fatal accidents such as overdose or the results of drinking and driving. From the nursing standpoint there are several interventions and strategies that can be instrumental in helping a family in crisis. Giving necessary support, providing educational resources and counseling resources are just three small areas that are important for the nurse to......

Words: 840 - Pages: 4

Nursing Assessment

...|Functional Health Pattern Assessment (FHP) | |Pattern of Health Perception and Health Management: | |How does the person describe current health? | |What does the person do to maintain health? | |What does person know about links between lifestyle and health? | |How big a problem is financing health care for this person? | |Can this person report his/her medications and the reason for taking them? | |If this person has allergies, what does he/she do to prevent/manage them? | |What does the person know about medical problems in his/her family? ...

Words: 456 - Pages: 2

Freedman Family Assessment Nursing 405

...Faye Glenn Abdellah’s Concept of Twenty One Nursing Problems Faye Abdellah believed that nursing was broadly grouped into 21 problem areas to guide care and promote the use of nursing judgment. She also believed that nursing is a comprehensive service that is based on the art and science and aims to help people, sick or well, cope with their health needs. 21 Nursing Problems 1. To maintain good hygiene. 2. To promote optimal activity; exercise, rest and sleep. 3. To promote safety. 4. To maintain good body mechanics. 5. To facilitate the maintenance of a supply of oxygen. 6. To facilitate maintenance of nutrition. 7. To facilitate maintenance of elimination. 8. To facilitate the maintenance of fluid and electrolyte balance. 9. To recognize the physiologic response of the body to disease conditions. 10. To facilitate the maintenance of regulatory mechanisms and functions. 11. To facilitate the maintenance of sensory functions. 12. To identify and accept positive and negative expressions, feelings and reactions. 13. To identify and accept the interrelatedness of emotions and illness. 14. To facilitate the maintenance of effective verbal and non-verbal communication. 15. To promote the development of productive interpersonal relationship. 16. To facilitate progress toward achievement of personal spiritual goals. 17. To create and maintain a therapeutic environment. 18. To facilitate awareness of self as......

Words: 403 - Pages: 2

Evaluating Comprehensive Approaches to Nursing Assessment for an Older Person with Multiple Health Problems

...A written assignment that evaluates comprehensive approaches to nursing assessment for an older person with multiple health problems. The account should reflect on how the multidisciplinary team and other agencies including the family, may contribute to these assessment approaches. Particular attention should be paid to national policies in this area and evidence of best practice. The patient that will be discussed within this assignment is a 70 year old male admitted to hospital following a stroke. Pressure ulcer risk assessments and nutritional risk assessments will be discussed within this assignment looking at how they are used in the assessment of an older people with multiple health problems. A stroke occurs when there has been a disturbance or cut off of blood flow within the brain, this disturbance damages or destroys brain cells preventing these cells from doing their job. Damage to the brain causes problems with bodily functions and can also affect mental processes (Stroke Association, 2010). A stroke can cause sudden weakness or paralysis which often only affects one side of the body and is one of the most common symptoms of a stroke. It can also cause swallowing difficulties (dysphagia), speech and language (dysphasia) can be affected also, patient may have difficulty in understanding and basic things such as reading and writing following stroke. Problems with eyesight, perception and interpretation, mental processes, bladder and bowels, mood swings, sensation......

Words: 4850 - Pages: 20

Nursing Gi Assessment

...Physical Assessment of the Gastrointestinal System  Walden University Physical Assessment of the Gastrointestinal System  The examination of the gastrointestinal system is an evaluation of the organs in the center of the body and the associated vasculature and lymphatics. Its functions are investigated by using inspection techniques of visual inspection, palpation (feeling with the hands), percussion (tapping with the fingers), and auscultation (listening). The purpose of this paper is to demonstrate the record of the findings resulting from the gastrointestinal physical assessment of patient Mr. J. |Week #4 | |Abdomen | |Contour/Symmetry | | | |Visual examination of the abdomen revealed symmetry bilaterally; no skin | | |abnormalities were found. There were no abdominal masses visible, and the| | ...

Words: 1133 - Pages: 5

Assessment and Diagnosis Nr443 Community Health Nursing

...Assessment and Diagnosis Kimberly Bowen NR443 Community Health Nursing Ellsworth Wisconsin in Pierce County is a smaller community of mostly farming, nestled in Northwestern Wisconsin it consist of 250 square miles. According to Wisconsin Department of Health Services (2013). Pierce County residents are among the healthiest in the state, according to the 2013 County Health Rankings released by the University of Wisconsin Population Health Institute (UWPHI) and the Robert Wood Johnson Foundation (RWJF). And Pierce County ranks in the top quartile for health outcomes and health factors. Pierce County ranks in the top quartile of Wisconsin counties for health behaviors and social and economic factors. Pierce County ranks in the top half of Wisconsin counties for clinical care but in the bottom half for physical environment, the physical environment that is going to be explored is water quality and the effects on this community. Ellsworth is a village in Pierce County, in the Minneapolis-Saint Paul metro area. It is the county seat. The community was named after Col. Elmer E. Ellsworth, killed in Virginia during the Civil War. The latitude of Ellsworth is 44.732N. The longitude is -92.487W. It is in the Central Standard time zone. Elevation is 1,214 feet (E Podunk, 2013), Col. Ellsworth became well known for his military tact’s and that is how the town got his name as a town, it was to honor him for his serves. Ellsworth is a small Ellsworth is 96.6 %......

Words: 1537 - Pages: 7

Community Assessment Nursing

...Assessment of Non-acute Health and Social Services in Ponchatoula, Louisiana Laura K. Ogden Southeastern Louisiana University College of Nursing and Health Sciences School of Nursing NLAB 334 October 29, 2014 Assessment of Non-acute Health and Social Services in Ponchatoula, Louisiana The community assessed was Ponchatoula, Louisiana. The focus of the assessment was non-acute health and social services. The community-as-partner model was used as a guide in understanding how the different parts of Ponchatoula’s community make up its core, and to apply the steps of the nursing process (Anderson and McFarlane, 2011). The assessment was based on observations of the community, interview data from a nursing home director, and selected published data related to the healthcare and social services assessed. Assessment data was analyzed, and conclusions and inferences drawn from the analysis will be presented in the paper. Windshield Survey On October 28th at approximately 4:00 pm an observation of Ponchatoula was conducted while driving through the city’s limits. This survey was done to acquire an overall health assessment of Ponchatoula’s environment including buildings and people out and about. The city itself appeared dated as evidenced by the architecture, especially on E. Pine St. However, for being the age they are, the buildings appeared well kept with clean paint jobs. Sidewalks lined each side of E....

Words: 2723 - Pages: 11

Family Nursing Diagnoses (Part 2 of the Programmatic Assessment)

...Outline I: Family Assessment   Summary findings of the family Assessment Watson’s Theory of human caring-Influences clinical thought and action in community and public health nursing II: Diagnosis according to the Family Assessment results     Nutritional guidelines-Overweight, Blood pressure and diabetes Link each diagnosis to a Healthy People 2020 LHI. Conducting a comprehensive and holistic assessment of participant family with consideration of the windshield Survey and Current research & develop a plan for the family & determine diagnosis. 3-5Legal and ethical considerations with the potential solutions/actions III: Nursing plan    Describe how you plan to advocate for the family within their community and involve the family members in becoming partners in their own health. Explain how the family’s health may be affected by family structure and roles. Identify family values that may be different from your own values and how this may affect the interventions. Educational tools and the benefits  Compile a list of topics and resources for the family’s health education needs, and explain why these resources were chosen Additional attachments   IV: V: Clinical Log for time spent conducting the Family Assessment Completed Family Assessment including survey questions and family answers Works Cited Appendixes VI: VII Currently in the health care industry, Nurses are dealing with biomedical and ethical dilemmas constantly arisen. It is clear......

Words: 5152 - Pages: 21

Family Nursing Calgary Assessment Paper

...Calgary Assessment of the Fournier Family Danielle Fournier Elmira College Abstract Assessment, the first step in the nursing process, is a concept that must grasped in order for nurses to possess the solid foundation required to develop a plan and provide optimal care to their patients. This assessment is significant not only to individual patients, but their families, who are becoming increasingly recognized for their significance to the health and well being of individual family members. Nurses use a variety of tools in family nursing, and one of the most significant includes the Calgary Family Assessment Model (CFAM), developed by Wright and Leahey. CFAM is an integrated conceptual framework used for interviewing and making assessments of families. It consists of three major categories, structural, functional and development, and each category contains its own subcategories. This paper will demonstrate the assessment of my family, the Fournier Family, using the Calgary Family Assessment Model. Strengths and weaknesses of the family will be determined, information which is necessary for the development of three significant nursing diagnosis applicable to the family. Interventions to meet the outcomes of these diagnoses arise through collaboration between the nurse and family, as they develop strategies to promote, improve, and sustain effective family functioning. Through the use of this model, assessment, diagnosis and interventions will each be identified and......

Words: 9785 - Pages: 40

Complete Nursing Physical Assessment

...ASSESSMENT Gather Equipment/Provide Privacy/Ensure Proper Lightening Wash Hands Ensure visualization of each body part as its examined Introduce self to patient (my name is….. how are you doing today) General Survey Say all of this… Can you state your age for me? Client appears to be stated age. LOC-Ask client: Can you tell me you name please, DOB, and where are you today, what month and year. Client is alert and oriented x3 -- to person, place, time Client’s skin color appears like pink and evenly pigmented without lesions or redness Client nutritional status appears appropriate for weight, height and body size. Client is sitting upright and appears to be relaxed and comfortable Clients body parts are intact and appear equal without no obvious physical deformities. Client is cooperative and smiling, expresses her feelings appropriate to the situation. Client’s speech is in a moderate tone, clear, and culturally appropriate. Upon general observation clients hearing is intact, she hasn’t asked me to repeat anything. Clients dress is appropriate to the season and client is cleaned and well groomed Ask her to walk a few feet and then walk back… State “ Gait is rhythmic and coordinated, with arms swinging at side., walk is smooth and well balanced” Posterior Lungs – stand behind client State out all parts as you inspect. Inspect rhythm, depth and pattern of breathing. State I’m going to inspect respirations for depth, rhythm, and pattern. Client’s......

Words: 5413 - Pages: 22

Hlten503B Contribute to Client Assessment and Developing Nursing Care Plans

...Implement and monitor nursing care for clients with acute health problems. Contribute to complex nursing care of clients. Administer and monitor medications. Administer and monitor IV meds. Assessment 2 Post-op Case Study Assessment 2 Question 1. Identify a minimum of 5 nursing actions, in order of priority you would perform related to above information. Mrs Abu has had a considerable change in her vital signs (blood pressure lowered, her pulse is rapid, her respirations increased and temperature has dropped) form the baseline taken before surgery. These findings alone would be reported to the Registered Nurse and monitored. But because of the changes in vital sings, coupled with Mrs Abu reporting light-headedness and nausea, plus her significant blood loss form the surgical wound, you would be assessing for hypovolemic shock which can be life threatening. As the nurse you would be seeking assistance immediately, assessing her airway, breathing and circulation. Applying oxygen, applying pressure at the surgical site and continuing to monitor (airway, breathing, circulation) and vital signs until help arrives. Mrs Abu should be given nil by mouth as she may return to surgery (Gulanick, Myers, Klopp, Galanes, Gandishar & Puzas 2003, p.329). Question 2. Complete the interventions and rationale in Mrs Abu's care plan related to the following diagnosis |Nursing Diagnosis |Interventions |Rationale ...

Words: 2084 - Pages: 9

Culture and Diversity in Nursing: Cultural Assessment

...Culture and Diversity in Nursing Amanda M. Jones Trinity Valley Community College Associate Degree Nursing Level II January 16, 2015 Culture and Diversity in Nursing Cultural Assessment With there being such a plethora of cultures in the world, there are so many different beliefs and practices involving health and wellness, that almost everyone has a different definition of health, and different views on disease and illness in general. My definition of health involves many different aspects, but most importantly living a healthy lifestyle overall; being free from illness, and doing everything possible to stay that way. Eating a well-balanced diet, exercising regularly, and getting plenty of sleep along with protecting your body from the harsh outside world, and maintaining proper hygiene are the most beneficial in being healthy. In fact, I believe that the main cause of illness aside from harmful pathogens and stress is lack of proper diet, exercise, sleep, and basic hygiene. Those things are essential to maintaining health. Anytime I start to get symptoms of a cold or illness, I immediately start taking vitamin C and drinking plenty of water. I usually do not seek medical care unless I am certain that I need antibiotics, as I like to take more of a holistic approach before using medicines any time possible. The same can be said about my pain management. I have a fairly high pain tolerance, and try to avoid using pain medications. When I am in pain I usually try......

Words: 1758 - Pages: 8

Community Nursing Assessment

...  I was  told by a neighbor, that in this block that there is one  hispanic family with nine people who reside in the same duplex  unit, three white families and ten black families.  There are  eight school aged children in this neighborhood.  Some of these  people have lived here for over thirty years.  The houses have  either wood or some type of aluminum/wood­like siding.  There  are no homes in this community that are made of brick.  The  community consists mainly of two story homes, there are at  least two or three duplex units in each block of the community.  The front yards are small, but have larger side or back yards.  Two of the homes have a driveway and, while most of the homes  have detached garages.  Population Economic Status Assessment        The 46202 area is home to approximately 16,335 people. The  median age of the population is thirty­two years old. The  majority of the population is white totaling 8,749, the second  highest population group is black consisting of 5,802 people  (USZIP, n.d.).         The median household income in 46202 is $33,000.  The  majority (60%) of the people are renters and 17% are  homeowners.  There are 1,319 people who receive food  stamps/public assistance.  There are approximately 29.8%  households at or below the poverty level and 32% of children  are living in poverty (County, 2014).  The composition of  low­income group by race:  African American 28%, Asian 16%, ......

Words: 3633 - Pages: 15

Transcultural Nursing Assessment

...Running head: Transcultural Nursing Assessment Transcultural Nursing Assessment Deborah Hill St. Francis University Abstract Giger and Davidhizar’s Transcultural Assessment Model is a valuable and functional assessment tool that evaluates the different cultural variables and how those variables effect health, illness and behaviors (Giger, 2013). This philosophy considers the uniqueness of each individual, understanding that the individual is unique, a product of their culture, religion, environment socioeconomic status and diversity. Giger and Dividhizar propose that, as health care providers, we need an acute awareness of the ethnicity and culture of each individual, having the knowledge and understanding to care for them as their culture, religion, values and belief system necessitates (Giger & Davidhizar, 2002). This model of nursing assessment focuses on six factors, or phenomena, that address important areas of cultural influence which impact our ability to provide diverse clients with the most effective and efficient care. The six phenomena are communication; space; social organization; time; environmental control; and biological variations. This assignment involves the use of the Transcultural Nursing Assessment model in the care of Ms. B, an 82 year old, African American female. Introduction America has been called the melting pot of the world. The term indicates that America is a county made up of immigrant cultures, religions and various......

Words: 4803 - Pages: 20

Nursing Assessment Global Outbreak

...California, August–September 2011. (2012, June 01). Retrieved April 26, 2016, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6121a1.htm Measles Risk Factors. (n.d.). Retrieved April 26, 2016, from http://www.mayoclinic.org/diseases-conditions/measles/basics/risk-factors/con-20019675 Measles Travels from Malaysia to 10 States. (2013). Retrieved April 25, 2016, from http://www.cdc.gov/ncezid/dgmq/feature-stories/measles-malaysia-10-states.html Notes from the Field: Measles Among U.S.-Bound Refugees from Malaysia --- California, Maryland, North Carolina, and Wisconsin, August--September 2011. (2011). Retrieved April 26, 2016, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6037a4.htm Stanhope, M., & Lancaster, J. (2006). Foundations of nursing in the community: Community- oriented practice. Retrieved April 25, 2016, from http://wgu.vitalsource.com/#/books/9780323100946/cfi/2/6!/4/2/14/30/6@0:25.3 The Department of Public Health. (2016). Retrieved April 26, 2016, from http://www.elpasotexas.gov/public-health/programs/epidemiology WHO | World Health Organization. (n.d.). Retrieved May 01, 2016, from http://www.who.int/ith/mode_of_travel/tcd_aircraft/en/...

Words: 1745 - Pages: 7