The last step in every assessment, except abdominal, is auscultation. This allows the nurse to listen to sounds produced by the patient’s body from their lungs to their arteries. HEENT: Inspect, palpate percuss, Respiratory: inspect, palpate, percuss, auscultate, Cardiac: inspect, palpate (arteries), auscultate, GI: inspect, auscultate, palpate, percuss, GU: inspect, palpate, percuss, auscultate, Musculoskeletal: inspect, palpate, auscultate, Integumentary: inspect, palpate, Neurological: inspect. However, when doing a comprehensive assessment, clustering your assessment by regions of the body is more efficient. “…from examination of the head and neck, the physician must identify the vascular, neurologic, lymphatic, skeletal, and integumentary components and must relate them to their complements in other body regions. It would be tedious, by contrast, to examine the vascular system in its entirety, followed by a complete neurologic examination and the other organ systems each in turn.” (Walker, 1990). I started off with inspecting Ms. Jones HEENT. Asking the patient about any issues in this region will allow you to focus your assessment. I started at the top of her head by inspecting and palpating her scalp. I moved onto her eyes by assessing her eye movements, visual acuity and peripheral vision. Following that, I inspected her ears with the otoscope and did the whisper
PATIENT ANALYSIS AND TEACHING TOOL 6 test. I completed the HEENT exam by palpating/auscultating her carotids and assessing her strength and ROM of her neck. Next, I moved onto the anterior chest to posterior chest by inspecting her chest movements, palpating for tactile fremitus and symmetric expansion and PMI. I moved onto percussing her lungs and concluded the chest exam through auscultation. Following that, I focused on the abdomen. Inspection came first followed by auscultation. Not only did I auscultate her bowel sounds but also her abdominal arteries. Next came palpation (light then deep). I ended the abdomen through percussion. I proceeded by focusing on the upper and lower extremities. I inspected for any abnormalities or edema. Next, I palpated her pulses. I moved on by assessing her neurological system in her extremities by testing pain, strength, ROM, motor skills, graphesthesia, stereognosis and position sense. Established Norms HEENT: Ms. Jones shows only one significant change in this section. The only deviation from the norm in this section is her mild retinopathic changes. This can be due to her diabetes - diabetes affects the vessels in the eyes which can lead to loss of vision. (NEI, 2015). Healthy adults of her age should not begin to show any significant changes in their eyes unless they have an underlying condition. The rest of her results compare with normal finds - her head is normocephalic and atraumatic. PERRLA with EOM’s intact bilaterally. She was able to whisper words heard bilaterally and has a positive gag reflex. Her oral mucosa is moist without ulcerations. No masses, lumps or tenderness noted on palpation. Her neck has full ROM with 5/5 strength.
PATIENT ANALYSIS AND TEACHING TOOL 7 Cardiovascular: Healthy adults in their 30’s should not have cardiovascular issues. One
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