physical assessment
Running
head
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SAMPLE
PAPER
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SAMPLE PAPER 3
Sample
Paper
Student A
Rasmussen College
COURSE#
:
NUR2180 Physical Assessment
Professor Casey Kelly
April 19, 2020
Title of Paper
Subjective Information
Patient states “…” this is the area where you put all of the subjective information the patient tells you, or that you gather – use your textbook “subjective” section to find the appropriate questions you would ask your patient about their symptoms related to the body system for this module.
1. Subjective data includes basic biographic data on the patient (name, age, race/ethnicity, gender assigned at birth)
· Did I mention if the patient is taking any daily medications? Did I mention if the patient has any allergies?
1. Subjective data mentions all aspects of PQRST
· P- Did I mention makes their symptoms better & what makes them worse
· Q- Did I mention the quality, characteristics, or descriptive factors of the symptoms?
· R- Did I mention the region affected? Is any radiation present?
· S- Did I mention the severity on a scale of 0-10?
· T- Did I mention when their symptoms first started and the duration of their presence?
Objective Information
This is where you would document your assessment findings – remember to include all of the assessment pieces for the body system- use your textbook for examples of what needs to be included. For most body systems you will need to include: Inspection, Palpation, Auscultation – but it depends on the body system. Do not document “normal” or “Okay” – you need to describe the assessment findings that lead you to believe it was normal or okay. For example, do not document “ears normal” document – “On inspection ears are symmetrical and free from redness and drainage.” Your Jarvis textbook “documentation” section in each chapter will provide you with a complete out line of what would be included in a full physical assessment for each body system- so please double check your textbook to make sure you have included all aspects of the exam.
Risk Factors
This is where you will think about your assessment findings and identify assessment items that put your patient at risk for something – for example if my patient has a wound on his foot he may be at risk for falls, or if my patient has been vomiting for three days she may be at risk for dehydration or electrolyte imbalance. Keep your risks nursing focused if possible – things that, as a nurse, you can help your patient with (nutrition, mobility, safety) – if you need help thinking of a risk use the resources found in the nursing library page- Reference Books – the Care Plans tab.
https://guides.rasmussen.edu/nursing/referenceebooks
For risk factors, make sure you have the following:
1. At least 2 actual or potential risk factors are listed for this patient
· Do these risk factors clearly pertain to the patient issue?
· Did I cite my information with in-text citations?
References
**** APA formatted references are included at the end of the assignment****
· APA guidelines can be found at
https://guides.rasmussen.edu/apa
Running head:
SAMPLE
PAPER
1
Sample
Paper
Student A
Rasmussen College
COURSE#
:
NUR2180 Physical Assessment
Professor Casey Kelly
April 19, 2020
Running head: SAMPLE PAPER
1
Sample Paper
Student A
Rasmussen College
COURSE#: NUR2180 Physical Assessment
Professor Casey Kelly
April 19, 2020
Running head: SAMPLE PAPER 1
SAMPLE PAPER 3
Gastrointestinal assessment
Hawa wolopa
Rasmussen College
COURSE#: NUR2180 Physical Assessment
Professor Casey Kelly
0ct 21, 2020
Title of Paper
Subjective Information
The patient is a 41-year-old Caucasian who is admitted with the diagnosis of gastrointestinal bleed. The patient is currently on Omeprazole, theanine, vitamin B, and folate supplement. The patient is allergic to morphine, Ibuprofen, and tetracycline. The patient states that 5 minutes before the nurse entering his room, he vomited bright red blood into the trash can. He also says that I should not have eaten the food because not eating has been the only thing not making me sick since being here. The patient also reported that he is feeling nauseous, exhausted, and anxious. When asked about his appetite, he states that he desires, but feels sick to his stomach and has been throwing up whenever he eats. He says that he feels more tired after throwing up. The patient denies having ulcer and gallbladder diseases. Patients report no symptoms of appendicitis or colitis but complain burning sensation in the Left upper quadrant that does not radiate and indigestion; report pain 4/10 on the scale of one to ten. She states that he feels much better when he takes Antacids—the patient report not having BM every day without discomfort.
Objective Information
On inspection of the patient, vital signs obtain Temp 36.5, HR 124Bpm, RR 24, and ` BP100/62mm Hg. Spo2 93%, weight 55kg, (last weight was 65kg) patient height is 178. Upon inspection: the patient abdomen distended asymmetrically. Umbilicus everted with significant ascites. Skin jaundiced with prominent vein distention. No open area, redness, or bruises noted. Auscultation: Bowel sounds noted hyperactive in all four’s quadrants, no swashing sound noted in all quadrant—palpation: Abdomen firm and slightly tender with muscle guarding. Skin feels warm touch, and intact.
Risk Factors
The patient might be at risk for Gastritis due to the bright red blood noted in his Emesis, feeling nauseated, ingestion. Also, Gastritis is inflammation of the stomach lining, and it depends on the location of the inflammation. Gastritis also leads to ulcers if not on time. The patient is also at risk for deficient fluid volume, leading to decreased urine output, poor or dry skin, increased thirst, and reduced blood pressure. Fluid loss leads to loss of electrolytes with the GI tracts.
References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing Care Plans : Guidelines for Individualizing Client Care Across the Life Span: Vol. 10th edition. F.A. Davis.