NURS 6512 Comprehensive (Head-to-Toe) Physical Assessment

NURS 6512 Comprehensive (Head-to-Toe) Physical Assessment

NURS 6512 Comprehensive (Head-to-Toe) Physical Assessment

Click here to ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: NURS 6512 Comprehensive (Head-to-Toe) Physical Assessment

SUBJECTIVE DATA:

 

Chief Complaint (CC): “I have come to the unit because I am needed to have a recent physical examination report for the healthcare insurance for my newly acquired job.’

History of Present Illness (HPI): Ms. J is a 28-year-old client that came to the unit for a physical examination report, as her new employer needs it for healthcare insurance. Ms. J reports during the encounter that she has secured an employment at Smith, Stevens, Stewart, Silver & Company. The company requires her to undergo a pre-physical examination before Ms. J begins working with them. Ms. J denied any acute concern during this visit to the hospital. She reports that she visited the hospital for physical examinations four months ago when she had gone for her yearly gynecological examination at the Shadow Health General Clinic. Ms. J reported that she was diagnosed with polycystic ovarian syndrome during this visit and was prescribed to use oral contraceptives, which she has been tolerating them well. Ms. J further reported that she has type 2 diabetes mellitus, which she currently controls with metformin, diet, and exercise. She was diagnosed with diabetes five months ago and reports no side effects with metformin. The self-reported health and wellbeing of Ms. J is that she is healthy and engaging in healthy behaviors and lifestyles, as a way of promoting her health. She is excited and looking forward to starting her job with the new organization.

Medications: Ms. J is currently using and has used a number of medications. They include the following:

Metformin 850 mg PO BID (she lastly used it this morning)

Fluticasone propionate 110 mcg 2 puffs BID (she lastly used it this morning)

Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (lastly used three months ago)

Drospirenone and ethinly estradiol PO QD (lastly used this morning)

Acetaminophen 500-1000 mg PO prn (headaches)

Ibuprofen 600 mg PO TID prn (for menstrual cramps, lastly taken 6 weeks ago)

 

Allergies: Ms. J reported history of drug allergy. She is allergic to penicillin, as it causes rash. She denies any history of food or latex allergies. She however reports that she is allergic to dust and cats. She reports that her exposure to dust or cats causes her running nose, swollen eyes, itchiness, and increase in the symptoms of asthma.

 

Past Medical History (PMH): Ms. J has significant medical histories. She has history of asthma that she was diagnosed with at the age of two and half years. She reports that she managers asthma symptoms using albuterol inhaler whenever she is exposed to allergens that include dust and cats. She reports that her last experience of asthma exacerbation was three months ago. She has a history of hospital admission due to asthma when she was in high school. As noted initially, Ms. J has type 2 diabetes mellitus. She was diagnosed with it when she was 24 years old. She currently manages the diabetes using metformin, which she started taking five months ago. She reports that she experienced gastrointestinal side effects at the beginning due to metformin but has dissipated since then. She reports that she monitors her blood glucose levels on a daily basis with the average reading being in the range of 90. Ms. J also has a history of hypertension. She reports that she normalized the elevated blood pressure by engaging in regular physical activity and dietary modifications.

Past Surgical History (PSH): Ms. J denied any history of surgeries.

Sexual/Reproductive History: Ms. J reported that her menarche was when she was 11 years old. Her first sexual encounter was when she was 18 years old. She identified that she has sex with men, hence, heterosexual. She denied any history of pregnancy or pregnancy loss. She noted that her last menstrual period was two weeks ago. She has a diagnosis of polycystic ovarian syndrome that was reached in the last four months during her annual gynecological visit. Ms. J reported experiencing moderate menstrual bleeding that last five days since she started using Yaz. Ms. J also reported that she is in a new relationship with a male that she has not engaged in any sexual relationship or contact. She expressed her intention to start using condoms with her boyfriend. She reported further that she tested negative for STIs and HIV/AIDS four months ago when she came for her annual gynecological visit. There was no history of sexually transmitted infections.

 

Personal/Social History: She denied any history of marriage and children. She has been living alone since the age of 19. She however lives currently with her sister and mother and is planning to relocate to live on her own in a month’s time. Ms. J reported that she is expected to report in her new place of work in two weeks’ time. She denied any recent travel to foreign countries. She does not have pets. She denied any history of psychiatric problems such as anxiety, suicidal thoughts, attempts, or plans, and depression. She appeared alert and oriented to self, others, time, events, and place. She also appeared well groomed for the occasion, engaged easily in the conversation, cooperative with pleasant mood. She did not demonstrate any abnormal behaviors such as tics, tremors, or facial fasciculation. The speech was or normal volume, rate, fluency, and clarity.

Health Maintenance: Ms. J reported using health promotion services. Her last pap smear screening was four months ago during her annual gynecological visit. She reported that she went for eye examination three months ago. She also reported that her last dental examination was five months ago. She took a tuberculosis test two years ago, which turned negative. Information about safety practices was obtained during the assessment. She reported that she has some detectors in their home, wears seatbelt whenever driving, and do not ride a bicycle. She reported using sunscreen. She has history of handling her father’s gun that is always locked in his room. Ms. J engages in mild to moderate physical activity at least four to five times on a weekly basis. The physical activity comprises of swimming, walking or yoga. She acknowledged that engaging in physical activity has helped her manage stress and improve her sleeping difficulties.

            When asked about her hobbies, Ms. J reported that she enjoys spending her time with friends, attending Bible study sessions, reading, and volunteering in her local church. She also reported that she enjoys dancing. She reported being an active member in her church. She attributed it to the influence of her family. She identified her family to be her source of social support. She also identified that church and her family helps her in coping with stressful situations. She denied history of tobacco use. She reported history of cannabis use since when she was 15. She stopped using it at age of 21. She denied use of methamphetamines, cocaine, and heroin. She reported occasional use of alcohol when she is with friends. The frequency of alcohol use was reported to be 2-3 times in a monthly basis. When asked about her dietary habits, Ms. J reported that her breakfast often comprises of fruit smoothie with sugar-free yoghurt. Her lunch comprises of sandwich on low-fat pita or wheat bread or vegetables with brown rice. Her dinner comprises of a protein and roasted vegetables, with carrot or apple snack. Ms. J denied use of coffee but acknowledged that she drinks 1-2 sodas on a daily basis.

 

Immunization History: Her immunization history showed that she received Tetanus booster jab within the last year, with her influenza vaccination not being current. She reported that she has not received human papillomavirus vaccine. She noted that she believes that her childhood vaccinations are up to date. She received meningococcal vaccine when she was in college.

Significant Family History: Ms. J has significant family histories. They include the following:

Mother: diagnosed with hypertension and elevated level of cholesterol. She is currently aged 50 years

Father: He is deceased through a car accident one year ago at the age of 58 years. He had hypertension, type 2 diabetes, and cholesterol.

Bother: aged 25 years and is overweight

Sister: she aged 14 years old and has asthma

Maternal grandmother: she died at the age of 73 years due to stroke. She had a history of high cholesterol and hypertension.

Paternal grandmother: Still alive, aged 82 years, and living with hypertension

Paternal grandfather: died at the age of 65 years due to colon cancer and a history of type 2 diabetes mellitus

Paternal uncle: suffers from alcoholism

Ms. J denied other cancers, mental illnesses, kidney disease, thyroid disorders, sickle cell anemia, and sudden death in the family.

Review of Systems:

General: Ms. J appears well groomed for the occasion. There are no signs of weight loss. She denied fatigue, weakness or recent illness. She also denies pain. She however reports that she feels that she has lost some weight due to her adoption of healthier lifestyles.

HEENT: Ms. J denies headaches. She uses corrective lenses. She denies changes in her vision since undergoing eye examination four months ago. She denies hearing loss, tinnitus or loss of body balance. She reports history of ear infection during her childhood period. She denies changes in taste or sense of smell. She also denied difficulty in swallowing. She reports that she underwent dental examination five months ago.

Respiratory: Ms. J reports history of asthma with its exacerbations experienced three months ago. She denies shortness of breath, wheezing, dyspnea, or coughing.

Cardiovascular/Peripheral Vascular: Ms. J denies palpitations, chest pains, arrhythmia or edema. She has history of hypertension.

Gastrointestinal: Ms. J denies any abdominal tenderness, swelling, pain, or changes in bowel movements. She also denies bloating, diarrhea, and stool stained with blood.

Genitourinary: Ms. J denies any changes in frequency and urgency of urinary bladder, dysuria, or passage of blood stained urine. She also denies changes in the smell or color of urine. She also denies any history of urinary tract infections.

Musculoskeletal: Ms. J reports history of right foot injury after she slipped off a stepping stool. She experienced gait problems after the injury. She denies any current gait problems. She also denies muscle weakness, pain and limited range of motions.

Neurological: Ms. J is alert and oriented to others, place, time, events, and space. She has clear, coherent speech. Her level of judgment is intact. She denies tingling sensations, numbing or decline in the level of sensation.

Psychiatric: She denies any history of psychiatric problems such as depression, anxiety, and suicidal thoughts, plans, or intentions.

Skin/hair/nails: Ms. J reports that acne has improved as well as the excessive growth of hair in the body since she used Yaz. She denies brittle nails or hair as well as changes in moles.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temp 37.2 C, HR 78, RR 15, BP 128.82, SPO2 99% room air, denies pain, height 170 cm, weight 84 kg, BMI 29, Random blood glucose 100 mg/dl

General: Ms. J appears appropriately dressed for the occasion. She denies fever, fatigue, and pain.

HEENT: The head is normocephalic with absence of evidence of trauma. She has bilateral eyes with equitable distribution of hair on the eyebrows and eyelashes. There is the absence of lesions, edema, or ptosis in the eyes. The conjunctiva appears pink without lesions. The sclera appears white with bilateral PERRLA. Extra-ocular muscles are intact with absence of nystagmus. There is the presence of mild changes in retinopathy on the right eye. The left fundus has sharp disc margins with no signs of hemorrhage. Snellen score is 20/20 for both eyes when the patient is using corrective lenses. There is the presence of positive light reflect. She hears whispered words bilaterally. The maxillary and frontal sinuses are not tender on palpation. The nasal mucosa appears pink with midline septum. The oral mucosa appears moist with the absence of lesions or ulcerations. There is midline rising of the uvula on phonation. The gag reflexes are intact. The dentition is normal with absence of signs of infection or dental caries. The thyroids are normal with absence of goiter or nodules. There is the absence of lymphadenopathy.

Neck: Absence of prominent veins raised jugular vein pressure, neck rigidity, and lymphadenopathy.

Chest/Lungs: The chest rises symmetrically with respirations with clear auscultation bilaterally. There is the absence of cough, wheezes, or labored breathing. There is the presence of resonance on percussion. The office spirometry results shows FVC of 3.91 L and FEV1/FVC ratio of 80.56%

Heart/Peripheral Vascular: Presence of regular heart rate with absence of adventitious heart sounds. The bilateral carotids are equal with the absence of bruit. The PMI is at the mid-clavicular line, with absence of lifts or heaves. The bilateral peripheral pulses are equal with capillary refill of less than 3 seconds. There is the absence of noticeable peripheral edema.

Abdomen: The abdomen is protuberant, symmetrical without visible scars, masses, or lesions. The client has normoactive bowel sounds in the four quadrants. There is tympanic in percussion of all the quadrants. Tenderness and guarding upon palpation are absent. Organomegally and CVA tenderness are absent.

Genital/Rectal: Not assessed, as no abnormalities or complaints were raised. 

Musculoskeletal: There are bilateral upper as well as lower extremities without evidence of masses, swelling, deformities or tenderness. The extremities have full range of motions. The client does not demonstrate any signs of pain with movement.

Neurological: The upper and lower extremities have 5/5 bilateral strength. The client has normal stereognosis, graphesthesia, and alternation of bilateral movements of the upper and lower limbs. The cerebellar function tests are normal. The muscle strength reflexes are equal bilaterally in the upper and lower extremities. There is the reduction in sensation to monofilament in the bilateral plantar surfaces.

Skin: The client has scattered facial pustules as well as facial hair on her upper lip. There is acanthosis nigricans on the posterior neck of the client.

Diagnostic results: Diagnostic investigations are not indicated because the client came for basic physical as well as health examination. The examination is needed prior to her employment in the new organization.

ASSESSMENT: Ms. J has come to the unit for a general physical examination, as a requirement by her new employer. She is currently using medications that include Flovent, Proventil, and metformin. She wore classes during the examination. She reports high tolerability for diabetes medication. She also uses other interventions such as exercise and dietary modification for diabetes management. She monitors the blood glucose level on a daily basis. She also has a history of asthma that is controlled using an inhaler. She is in a relationship and considers using condom in her sexual encounters with her boyfriend. She is on birth control to help her in the management of polycystic ovarian syndrome.

 

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.

Photo Credit: Getty Images/Hero Images

To Prepare

Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.

Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.

DCE Comprehensive Physical Assessment:

Complete the following in Shadow Health:

Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 9 Day 7 deadline.

Submission and Grading Information

By Day 7 of Week 9

Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.
Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.
Note: You must pass this assignment with a minimum score of 80%  in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
Grading Criteria

To access your rubric:

Week 9 Assignment 3 DCE Rubric

Submit Your Assignment by Day 7 of Week 9

To submit your Lab Pass:

Week 9 Lab Pass

To sumit this required part of the Assignment:

Week 9 Documentation Notes for Assignment 3

To Submit your Student Acknowledgement Form:

Submit your Week 9 Assignment 3 DCE Student Acknowledgement Form

Click here to ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: NURS 6512 Comprehensive (Head-to-Toe) Physical Assessment

What’s Coming Up in Week 10?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

Next week, you will examine how to assess problems with the breasts, genitalia, rectum, and prostate while making the patient feel safe, listened to, and cared about using a non-invasive approach. Once again, you will use a SOAP note format to complete your Lab Assignment for this week.

Week 10 Required Media

Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images

Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Lab Assignment on time.

Next Week

To go to the next week:

Week 10

Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal

The ability of the examiner to put the patient at ease is a critical component of any physical exam. By putting the patient at ease, nurses are more likely to obtain quality, meaningful information that will assist the patient in receiving the best possible care. Exams often go more smoothly when students feel safe, heard, and cared about. This is especially true when dealing with issues involving the breasts, genitals, prostates, and rectums, which many patients find difficult to discuss. As a result, it is critical to gain a firm understanding of how to obtain vital information and perform necessary assessment techniques in the least invasive manner possible.

For this week, you explore how to assess problems with the breasts, genitalia, rectum, and prostate.

Learning Objectives

Students will:

Evaluate abnormal findings on the genitalia and rectum
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum

Learning Resources

Required Readings (click to expand/reduce)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 17, “Breasts and Axillae”

This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.
Chapter 19, “Female Genitalia”

In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.
Chapter 20, “Male Genitalia”

The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.
Chapter 21, “Anus, Rectum, and Prostate”

This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 5, “Amenorrhea”
Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.

Chapter 6, “Breast Lumps and Nipple Discharge”
This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.

Chapter 7, “Breast Pain”
Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history.

Chapter 27, “Penile Discharge”
The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam.

Chapter 36, “Vaginal Bleeding”
In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis.

Chapter 37, “Vaginal Discharge and Itching”
This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 3, “SOAP Notes” (Previously read in Week 8)

Cucci, E., Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015). Sclerosing adenosis of the breast: Report of two cases and review of the literature. Polish Journal of Radiology, 80, 122–127. doi:10.12659/PJR.892706. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/

Sabbagh , C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., & Regimbeau, J. M. (2014). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085. doi:10.1016/j.dld.2014.08.045

Westhoff , C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and technology make the rou