Rasmussen University Nursing Question
Description
Use these attached files for your assessment–Upload both files to the drop box. Write a summary of the assessment on the last page of the file. Answer the following questions in the summary and do not disclose any patient identifiers.
What skills (assessment techniques) were utilized during the assessment?
What subjective data did you collect? (list your findings)
What objective data did you collect? (list your findings
Unformatted Attachment Preview
Chapters 19 &20-Regional Write Up-Thorax and Lungs & Heart
Name:___________________________________________Date:_________________________
Patient Initials:______________________________Age:____________Gender:_____________
I Health History-Subjective Data (yes no answers-all yes answers explain)
Thorax and Lungs & Heart
1. Do you have a cough?__________________________________________________________
2. Any shortness of breath?________________________________________________________
3. Any chest pain with breathing?___________________________________________________
4. Any chest pain or tightness?_____________________________________________________
5. Do you seem to tire easily?______________________________________________________
6. Do you sleep with more than one pillow?__________________________________________
7. Does your skin ever turn blue or ashen?___________________________________________
8. Do you have any swelling of the feet or legs?_______________________________________
9. Do you awaken at night to urinate?_______________________________________________
10. Ever smoke cigarettes? How many/per day? Alcohol use? Number of Drinks a Day?_______
______________________________________________________________________________
11. Any living or work conditions that affect your breathing?_____________________________
12. Last TB skin test, chest x-ray, flu vaccine?________________________________________
13. Any past history of heart or lung disease?_________________________________________
14. Assess personal and familial cardiac risk factors: diabetes, hypertension, smoking, high
cholesterol, obesity, sedentary lifestyle,
age?__________________________________________________________
______________________________________________________________________________
II Physical Exam-Objective Data-Thorax and Lungs & Heart
A. Inspection
1. Thorax cage_________________________________________________________________
2. Respiratory rate and pattern_____________________________________________________
3. Overall skin and nail color______________________________________________________
4. Patientàposition______________________________________________________________
5. Facial expression_____________________________________________________________
6. Level of consciousness_________________________________________________________
B. Palpation
1. Confirm symmetric chest expansion_______________________________________________
2. Tactile fremitus_______________________________________________________________
3. Detect any lumps, masses or tenderness____________________________________________
4. Trachea_____________________________________________________________________
C. Auscultation
1. Listen to anterior, posterior and lateral lung sounds__________________________________
2. Note any adventitious lung sounds?______________________________________________
D. Carotid Arteries
1. Palpate and grade R____________________________L______________________________
(0=absent, 1+=weak, 2+=normal, 3+=increased,4+=bounding)
2. Auscultate the carotid arteries for Bruits___________________________________________
Health Assessment-Regional Write Up-2022
E. Precordium
1. Skin color and condition________________________________________________________
2. Chest wall pulsations__________________________________________________________
3. Heave or lift_________________________________________________________________
E. Precordium continued
4. Note Location: Palpate the apical impulse in the ________ or _________intercostal space at
the __________________________________________line.
F. Auscultation
1. Rate and rhythm______________________________________________________________
2. Note any murmurs_____________________________________________________________
(Auscultate heart sounds in the aortic, pulmonic, erbàpoint, tricuspid and mitral area)
Summary Thorax and Lungs & Heart
Write a paragraph reporting all of your subjective and objective findings:
Health Assessment-Regional Write Up-2022
Chapters 21-Regional Write Up-Peripheral Vascular and Lymph
Name:___________________________________________Date:_________________________
Patient Initials:______________________________Age:____________Gender:_____________
I Health History-Subjective Data (yes no answers-all yes answers explain)
Peripheral Vascular and Lymph
1. Any leg pain (cramps)? Where?__________________________________________________
2. Any skin changes in arms or legs?________________________________________________
3. Any sores or lesions in arms or legs?______________________________________________
4. Any swelling in the legs?_______________________________________________________
5. Any swollen glands? Where?____________________________________________________
6. What medications are you taking?________________________________________________
II Physical Exam-Objective Data-Arms
A. Inspection
1. Color of skin and nail beds______________________________________________________
2. Symmetry___________________________________________________________________
3. Lesions_____________________________________________________________________
4. Edema______________________________________________________________________
5. Clubbing____________________________________________________________________
B. Palpate
1. Temperature_________________________________________________________________
2. Texture_____________________________________________________________________
3. Capillary refill_______________________________________________________________
4. Locate and grade pulses-0=absent, 1+=weak, 2+=normal, 3+=bounding
Brachial
Radial
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibial
Right
Left
Physical Exam-Objective Data-Legs
A. Inspection
1. Color_______________________________________________________________________
2. Hair distribution______________________________________________________________
3. Venous pattern/varicosities______________________________________________________
4. Note swelling or edema________________________________________________________
5. Atrophy_____________________________________________________________________
6. Skin lesions or ulcers__________________________________________________________
7. Observe for DVTß___________________________________________________________
B. Palpate
1. Temperature_________________________________________________________________
2. Check for tenderness__________________________________________________________
3. Check for edema (absent/present, if present rate edema +1, +2, +3, +4)___________________
Perform modified Allen test (describe results)_______________________________________
***Test is used to ??:____________________________________________________________
***Test is most commonly performed by??___________________________________________
Health Assessment-Regional Write Up-2022
Summary Peripheral Vascular and Lymph
Health Assessment-Regional Write Up-2022
Chapters 21-Regional Write Up-Abdomen
Name:___________________________________________Date:_________________________
Patient Initials:______________________________Age:____________Gender:_____________
I Health History-Subjective Data (yes no answers-all yes answers explain)
Abdomen
1. Any changes in appetite? Loss?__________________________________________________
2. Any difficulty swallowing?_____________________________________________________
3. Any foods you cannot tolerate?__________________________________________________
4. Any abdominal pain?__________________________________________________________
5. Any nausea or vomiting?_______________________________________________________
6. How often are bowel movements?________________________________________________
7. Any past history of GI disease?__________________________________________________
8. What medications are you taking?________________________________________________
II Physical Exam-Objective Data-Abdomen
A. Inspection
1. Contour of abdomen___________________________________________________________
2. General symmetry_____________________________________________________________
3. Skin color and condition________________________________________________________
4. Pulsations or movement________________________________________________________
5. Umbilicus___________________________________________________________________
6. State of hydration and nutrition__________________________________________________
7. Personàfacial expression and positon in bed_______________________________________
B. Auscultation
1. Bowel sounds________________________________________________________________
C. Palpation
1. Perform light and deep palpation in all four quads-Note tenderness, enlarged organs or
masses________________________________________________________________________
2. Assess for rebound tenderness___________________________________________________
3. Assess for CVA tenderness______________________________________________________
(Rebound tenderness and CVA tenderness are more commonly performed by a Physician)
Advanced Practice-Performed by a Physician
Note abnormal pathology of a positive sign or test
**Rebound Tenderness (Blumberg Sign)_____________________________________________
**Inspiratory Arrest (Murphy Sign)_________________________________________________
**Iliopsoas Muscle Test__________________________________________________________
Health Assessment-Regional Write Up-2022
Summary of Abdomen
Health Assessment-Regional Write Up-2022
Purchase answer to see full
attachment
Name:___________________________________________Date:_________________________
Patient Initials:______________________________Age:____________Gender:_____________
I Health History-Subjective Data (yes no answers-all yes answers explain)
Thorax and Lungs & Heart
1. Do you have a cough?__________________________________________________________
2. Any shortness of breath?________________________________________________________
3. Any chest pain with breathing?___________________________________________________
4. Any chest pain or tightness?_____________________________________________________
5. Do you seem to tire easily?______________________________________________________
6. Do you sleep with more than one pillow?__________________________________________
7. Does your skin ever turn blue or ashen?___________________________________________
8. Do you have any swelling of the feet or legs?_______________________________________
9. Do you awaken at night to urinate?_______________________________________________
10. Ever smoke cigarettes? How many/per day? Alcohol use? Number of Drinks a Day?_______
______________________________________________________________________________
11. Any living or work conditions that affect your breathing?_____________________________
12. Last TB skin test, chest x-ray, flu vaccine?________________________________________
13. Any past history of heart or lung disease?_________________________________________
14. Assess personal and familial cardiac risk factors: diabetes, hypertension, smoking, high
cholesterol, obesity, sedentary lifestyle,
age?__________________________________________________________
______________________________________________________________________________
II Physical Exam-Objective Data-Thorax and Lungs & Heart
A. Inspection
1. Thorax cage_________________________________________________________________
2. Respiratory rate and pattern_____________________________________________________
3. Overall skin and nail color______________________________________________________
4. Patientàposition______________________________________________________________
5. Facial expression_____________________________________________________________
6. Level of consciousness_________________________________________________________
B. Palpation
1. Confirm symmetric chest expansion_______________________________________________
2. Tactile fremitus_______________________________________________________________
3. Detect any lumps, masses or tenderness____________________________________________
4. Trachea_____________________________________________________________________
C. Auscultation
1. Listen to anterior, posterior and lateral lung sounds__________________________________
2. Note any adventitious lung sounds?______________________________________________
D. Carotid Arteries
1. Palpate and grade R____________________________L______________________________
(0=absent, 1+=weak, 2+=normal, 3+=increased,4+=bounding)
2. Auscultate the carotid arteries for Bruits___________________________________________
Health Assessment-Regional Write Up-2022
E. Precordium
1. Skin color and condition________________________________________________________
2. Chest wall pulsations__________________________________________________________
3. Heave or lift_________________________________________________________________
E. Precordium continued
4. Note Location: Palpate the apical impulse in the ________ or _________intercostal space at
the __________________________________________line.
F. Auscultation
1. Rate and rhythm______________________________________________________________
2. Note any murmurs_____________________________________________________________
(Auscultate heart sounds in the aortic, pulmonic, erbàpoint, tricuspid and mitral area)
Summary Thorax and Lungs & Heart
Write a paragraph reporting all of your subjective and objective findings:
Health Assessment-Regional Write Up-2022
Chapters 21-Regional Write Up-Peripheral Vascular and Lymph
Name:___________________________________________Date:_________________________
Patient Initials:______________________________Age:____________Gender:_____________
I Health History-Subjective Data (yes no answers-all yes answers explain)
Peripheral Vascular and Lymph
1. Any leg pain (cramps)? Where?__________________________________________________
2. Any skin changes in arms or legs?________________________________________________
3. Any sores or lesions in arms or legs?______________________________________________
4. Any swelling in the legs?_______________________________________________________
5. Any swollen glands? Where?____________________________________________________
6. What medications are you taking?________________________________________________
II Physical Exam-Objective Data-Arms
A. Inspection
1. Color of skin and nail beds______________________________________________________
2. Symmetry___________________________________________________________________
3. Lesions_____________________________________________________________________
4. Edema______________________________________________________________________
5. Clubbing____________________________________________________________________
B. Palpate
1. Temperature_________________________________________________________________
2. Texture_____________________________________________________________________
3. Capillary refill_______________________________________________________________
4. Locate and grade pulses-0=absent, 1+=weak, 2+=normal, 3+=bounding
Brachial
Radial
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibial
Right
Left
Physical Exam-Objective Data-Legs
A. Inspection
1. Color_______________________________________________________________________
2. Hair distribution______________________________________________________________
3. Venous pattern/varicosities______________________________________________________
4. Note swelling or edema________________________________________________________
5. Atrophy_____________________________________________________________________
6. Skin lesions or ulcers__________________________________________________________
7. Observe for DVTß___________________________________________________________
B. Palpate
1. Temperature_________________________________________________________________
2. Check for tenderness__________________________________________________________
3. Check for edema (absent/present, if present rate edema +1, +2, +3, +4)___________________
Perform modified Allen test (describe results)_______________________________________
***Test is used to ??:____________________________________________________________
***Test is most commonly performed by??___________________________________________
Health Assessment-Regional Write Up-2022
Summary Peripheral Vascular and Lymph
Health Assessment-Regional Write Up-2022
Chapters 21-Regional Write Up-Abdomen
Name:___________________________________________Date:_________________________
Patient Initials:______________________________Age:____________Gender:_____________
I Health History-Subjective Data (yes no answers-all yes answers explain)
Abdomen
1. Any changes in appetite? Loss?__________________________________________________
2. Any difficulty swallowing?_____________________________________________________
3. Any foods you cannot tolerate?__________________________________________________
4. Any abdominal pain?__________________________________________________________
5. Any nausea or vomiting?_______________________________________________________
6. How often are bowel movements?________________________________________________
7. Any past history of GI disease?__________________________________________________
8. What medications are you taking?________________________________________________
II Physical Exam-Objective Data-Abdomen
A. Inspection
1. Contour of abdomen___________________________________________________________
2. General symmetry_____________________________________________________________
3. Skin color and condition________________________________________________________
4. Pulsations or movement________________________________________________________
5. Umbilicus___________________________________________________________________
6. State of hydration and nutrition__________________________________________________
7. Personàfacial expression and positon in bed_______________________________________
B. Auscultation
1. Bowel sounds________________________________________________________________
C. Palpation
1. Perform light and deep palpation in all four quads-Note tenderness, enlarged organs or
masses________________________________________________________________________
2. Assess for rebound tenderness___________________________________________________
3. Assess for CVA tenderness______________________________________________________
(Rebound tenderness and CVA tenderness are more commonly performed by a Physician)
Advanced Practice-Performed by a Physician
Note abnormal pathology of a positive sign or test
**Rebound Tenderness (Blumberg Sign)_____________________________________________
**Inspiratory Arrest (Murphy Sign)_________________________________________________
**Iliopsoas Muscle Test__________________________________________________________
Health Assessment-Regional Write Up-2022
Summary of Abdomen
Health Assessment-Regional Write Up-2022
Purchase answer to see full
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