Clinical Assessment Notes

Introduction

• Name of Nurse: Lisa
• Patient Name and DOB: Elizabeth Nosek, 3-11-94
• Reason for Visit: General checkup
• Patient Orientation: Alert and oriented x4

Preliminary Questions

• Allergies: None reported
• Pain Scale: 0 out of 10

Vital Signs and General Appearance

• Vital Signs: Temperature, heart rate, respirations, blood pressure, O2 saturation within normal limits
• Appearance:
  • Age: Appears as stated age
  • Skin color: Even and appropriate for ethnicity
  • Facial features: Symmetric, no acute distress
  • Posture: Upright, symmetrical, no deformities
  • Height and weight: Appropriate for body stature
  • Hygiene: Clean hair, dressed appropriately for the weather

Head-to-Toe Assessment

Head and Eyes

• Head: Normal cephalic, no lumps or lesions
• Glasses: Worn for distance vision
• Pupils: Equal, round, reactive to light, and accommodate bilaterally
• Conjunctiva and Sclera: Pink and white respectively

Ears and Hearing

• Hearing aids: None
• Environmental factors: No loud noise exposure
• Internal Ear: No redness or drainage, some piercings present, no pain or skin breakdown

Nose and Sinuses

• Nares: Patent bilaterally, no drainage or redness
• Trauma or Surgery: None reported

Mouth and Throat

• Mucous Membranes: Pink and moist
• Teeth: Intact
• Uvula: Rises and falls midline
• Lips: Pink, moist

Neck

• Range of Motion: Full
• Carotid Pulses: +2 bilateral
• Bruits: None on auscultation

Chest and Lungs

• Breathing: No labored breathing, no accessory muscle use
• Lung Sounds: Clear bilaterally, no adventitious sounds

Heart

• Heart Sounds: Regular S1 and S2, no murmurs or extra sounds
• Apical Pulse: 86 beats per minute, regular

Skin

• Condition: Warm, pink undertones, no tenting, lumps, lesions, or tattoos
• Radial Pulse: +2 bilaterally
• Capillary Refill: Less than 3 seconds
• Nails: Short, round, clean, no clubbing

Abdomen

• Contour: Flat to rounded
• Umbilicus: Midline
• Bowel Sounds: Active in all four quadrants
• Palpation: No pain or tenderness

Extremities

• Pedal and Posterior Tibial Pulses: +2 bilaterally
• Edema: None present
• Muscle Strength: 5 out of 5 in upper and lower extremities

Conclusion

• Questions for Patient: None
• Post-Assessment: Patient given call light, bed low and locked