Family Health University College BSc Nursing Program Physical Assessment Assignment PDF

FAMILY HEALTH UNIVERSITY COLLEGE PHYSICAL ASSESSMENT ASSIGNMENT **As a Level 300 nursing student, recall a patient you rendered care to during a recent clinical session, indicate his/her diagnosis and conduct a physical assessment on him/her?** **THIS IS A TEMPLATE TO GUIDE YOU** **Biographic Da...

FAMILY HEALTH UNIVERSITY COLLEGE PHYSICAL ASSESSMENT ASSIGNMENT **As a Level 300 nursing student, recall a patient you rendered care to during a recent clinical session, indicate his/her diagnosis and conduct a physical assessment on him/her?** **THIS IS A TEMPLATE TO GUIDE YOU** **Biographic Data** Name: Address: Age: DOB: Birth Place: Sex: Marital Status: Race: Religion: Occupation: Social Security Number. Source of referral: Usual source of healthcare: Source of information: Informants: NHIS: **Date of first encounter:** **REASON FOR HEALTH ENCOUNTER:** To assess students' competence in health care data collection and performing and recoding findings from physical examinations into the database **PRESENT STATE OF HEALTH** **General state of health**: client is a healthy male, small in stature, well nourished, well oriented to time place and person, **Health goals**: To manage stress related to work and school, exercise at least twice a week and to eat regularly on time. **Definition of health:** client defines health as "good health equals good life" you have good health you have life. **Chief complaints** severe back ache accompanied by fatigue and light headedness. **Reason for seeking care today**: I have fainted twice this week **History of present illness** **ONSET** 2 days ago **Location** spines and head **Duration** days maximum 3 **Caracter** arching spines and light headedness **Aggravating factors** weekdays night shift and full day weekends school combine **Relieving factors** less activity, sleep and pain killers **Timing** pain is severe if I have to come to class right after night shift, or move about more frequently have been experiencing this for the past 18 months **Severity** on a pain scale of 1 to 10, pain is measure as 8 **Allergies**: NSAIDS What are your expectations for seeking care today: to ascertain what really happening to me and treat it ones and for all **Past health history:** has been in state of complete good health, has no known medical, surgical or mental conditions. **Childhood illness** chicken pox dx **Hospitalization**: twice **Reason for hospitalization:** malaria and allergic reactions (NSAIDS) **Accident/injuries:** broke left tibia from a fall at age 15 **Acute / chronic illnesses:** none **Immunization** fully immunized **Transfusion**: none **Allergies** NSAID **Alcohol** occasionally **FAMILY HISTORY** **MEDICAL HISTORY OF FAMILY** **ENVIRONMENTAL HISTORY**. **PSYCHOSOCIAL HISTORY.** **REVIEW OF SYSTEMS** Temp-37.6◦c Pulse-77bpm Resp-18cpm Spo2-99% Wt: 86kg RBS-5mmol/L Young adult, well hydrated, not pale, febrile (37.6), unsteady gait, lightheaded, headache, blurred vision (not today), has lost weight **Skin** Dark, warm skin with hair evenly distributed across, well hydrated and moist, and well elastic and not jaundiced. Cyanosis Nill Scars Nill Edema Nill Rashes/Lesions Nill Hair color and distribution Dark and spares Nails Vascularized, lanula present, smooth and well kept Stretch marks Nill wrinkles Nill **Head** The skull is symmetrical, face is well rounded with no protrusions, no tenderness (occipital bones flattened) - Hair is dark and healthy, not scaly or discolored - Hairline diminishing gradually due to baldness - Lesions Nill - Scalp free of flaking, no nits, dandruffs found - Deformities none **Eyes** Small in appearance, with some brown pigmentation in the left iris of no known cause, palpable fissures appear oval and symmetrical, equal in size when eyes are opened. Lid margin are clear and lacrimal ducts are present at the nasal end of both upper and lower lids. Globes No protrusions Upper lid covers a small portion of the iris and cornea, looks wrinkled when eyes opened Lower lid margin is just below the junction of the cornea and sclera, looks moist Ptosis Nill Eyelashes evenly distributed Sclera tarted and brownish in appearance Lens transparent Cornea transparent in right eye, translucent in left Retina no exudate or hemorrhages **Ears** External ear symmetrical, small (1.7cm) in diameter, and well flattened on the head, not discolored, no lesion found, Auditory canal clean (both ears) with minimal cerumen, ear on palpation was firm, with no tenderness, ear lobes are soft and elastic. Ear drums translucent, no perforations present. Could hear whisper sound from 15 feet clearly, confirms sound is lateralized equally in both ears. Weber's test Not done Rinne's test Not done **Nose and sinuses** Prominent Slightly pointed, not discolored, nasal septum is unperforated and straight, no discharges noticed, airway is patent, mucus membrane is pink on observation. Sinuses not tender. **Mouth** Lips are small and symmetrical, sightly pink, not dry, no masse and ulcers present mouth is clean with no palpable masses. Teeth white and 32 in number, no plaques notice Gums moist, pink, not spongy slightly ruff, no bleeding noticed. Tongue situated medially, pink, of average size Uvular medially situated, not covered by exudate or swollen Breath odorless Voice clear without hoarseness Throat pink and vascularized, no sores identified **Neck** Cervical nodes not palpable Trachea medially situated and symmetrical, no palpable neck mass Lymph nodes small, hardly palpable, freely moveable not tender. **Respiration patten** No accessary muscles involved Resp-18cpm, Spo2-99% Cough None Airway Clear Breath sounds no crept sounds **Cardiovascular** Pulse-77bpm, BP-129/90mmHg Chest pain nill Dyspnoea nill Palpitations nill **Gastrointestinal** Swallowing no pain Vomiting nill Nausea yes Bowel movement 2 daily (freely)