Nursing Patient Assessment

Introduction

• Nurse's Introduction: Nurse Lisa performing the assessment.
• Patient Information:
  • Name: Elizabeth
  • Date of Birth: March 11, 1994
• Reason for Visit: General check-up

Initial Assessment

• Patient Alertness: Patient is alert and oriented (time, place, person, and situation).
• Pain Level: Reports no pain (0 out of 10 scale).
• Allergies: None reported.
• Vital Signs:
  • Temperature, heart rate, respirations, blood pressure, and oxygen saturation are within normal limits.

General Observations

• Appearance:
  • Appears seated appropriately for age.
  • Skin color is even and appropriate for ethnicity.
  • Facial features symmetric.
  • No signs of acute distress.
  • Upright and symmetrical posture.
  • Appropriate height and weight.
  • Clean hair and clear articulation.
  • Good hygiene and dressed appropriately for weather.

Head-to-Toe Assessment

Head

• Hair: No lumps, lesions, or infestations. Normal cephalic shape.
• Eyes:
  • Wears glasses (for nearsightedness).
  • Pupils equal, round, and reactive to light and accommodation.
  • Conjunctiva is pink; sclera is white.

Ears

• Hearing: No hearing aids; no exposure to loud noises.
• Inspection: No redness or drainage; piercings noted without pain; no skin breakdown behind ears.

Nose

• Inspection: No drainage, redness, or deviated septum.
• Airway: Nares patent bilaterally.

Mouth

• Inspection:
  • Mucous membranes are pink and moist.
  • Teeth intact; uvula rises midline.
  • Lips are pink and moist.

Neck

• Range of Motion: Full range of motion.
• Pulse: Carotid artery pulse +2 bilaterally.
• Examination: No bruits noted.

Chest and Lungs

• Breathing: No labored breathing or use of accessory muscles.
• Lung Sounds: Clear bilaterally; no adventitious sounds.

Heart

• Heart Sounds: S1 and S2 regular; no murmurs.

Skin

• Condition: Warm, pink undertones; no tenting, lumps, lesions, scars, or tattoos.
• Pulses: Radial pulse +2 bilaterally; capillary refill <3 seconds.
• Nails: Short, round, clean; no clubbing.

Abdomen

• Contour: Flat to rounded; umbilicus midline.
• Inspection: No lumps, lesions, pulsations, or hernias.
• Bowel Sounds: Active in all four quadrants.
• Palpation: No pain or tenderness.

Lower Extremities

• Pulses: Pedal and posterior tibial pulse +2 bilaterally.
• Edema: No edema present.

Muscle Strength

• Upper and Lower Extremities: 5 out of 5 muscle strength.

Conclusion

• Complete Assessment: Concluded with no additional questions from the patient.
• Patient Comfort: Ensured patient had call light and bed was in low position before leaving.

These notes provide a comprehensive overview of the patient assessment conducted by Nurse Lisa, demonstrating key observations and the patient's status during the check-up.