Client/Patient Initials: DN| Sex: M| Age: 66 | Occupation of Client/Patient: Retired|
Health History/Review of Systems(Complete and systematic review of systems)| Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):No complaints of headaches, no past head injuries, no complaints of dizziness, no history of convulsion, tremors or weakness. The patient states he has had no numbness, tingling, or unsteady gait. The patient denies dysphagia or dysphasia. | Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications):The patient denies head pain, head or neck injury or trauma, no nodules or surgeries. The patient denies taking medication for head or neck. | Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):The patient does wear corrective glasses.
The patient denies redness or swelling in eyes nor watering. The patient denies history of eye injury or surgery. | Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):The patient denies ear pain or recent ear infections. The patient does have a bandage to right ear stating he just “had skin cancer removed”. Incision intact. No surrounding redness or swelling. The patient denies drainage. The patient denies vertigo. | Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):The patient denies sore throat, runny nose, or sores to mouth. The patient has poor dentition and states he sees a dentist regularly.
The patient states he brushes his teeth twice daily. The patient denies seasonal allergies. | Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications):The patient denies excessive dryness or excessive moisture to skin. The patient states history of skin cancer. The patient states he has had several “spots removed” for skin cancer including his nose, right ear, and cheek. The patient denies bruising easily. | Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):The patient denies pain or tenderness to breasts. The patient denies rash or swelling to breasts. | Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):The patient denies leg pain or cramping. The patient denies swelling in lower extremities and denies taking medications to increase circulation. | Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications):The patient states he has a history of heart attack and high blood pressure. The patient denies shortness of breath or recent chest pain. The patient states he currently takes Coreg and Aspirin daily. | Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications):The patient denies cough or shortness of breath. The patient denies chest pain upon inspiration or expiration.
The patient denies lung disease. The patient states he stopped smoking 32 years ago. The patient states he is up to date on his flu vaccination as well as his pneumonia vaccination. | Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications):The patient denies joint pain or stiffness. The patient denies muscle pain or cramping. The patient denies deformity of bones or joint. The patient denies history of trauma or accident to bones or muscle. The patient denies debilitation to activities of daily living. | Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications):The patient denies changes in appetite. The patient denies difficulty swallowing. The patient denies foods that are not tolerated. The patient denies frequent nausea or vomiting. The patient states he has a regular bowel movement daily. The patient denies history of GI ulcers or taking medications for GERD or acid reflux. | Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, suprapubic region or low back):The patient denies urgency, frequency, or dysuria. The patient denies polyuria.
The patient states history of kidney stones. The patient denies incontinence or flank pain. The patient denies groin pain or low back pain. | Physical Examination(Comprehensive examination of each system. Record findings.)| Neurological System (exam of all 12 cranial nerves, motor and sensory assessments):Cranial Nerve I – Sense of smell intact evidenced by smelling an onion as well as cinnamon with eyes closed. Cranial Nerve II – Snellen eye chart eye exam shower 20/40 in bilateral eyes without corrective lenses. Patient is 20/20 in bilateral eyes with corrective lenses. Cranial Nerve II, IV, and VI – Pupils equal, round, and reactive to light and accommodation. Extraocular movements are within normal limits. Cranial Nerve V – Mastication muscles are equal bilaterally. Cranial Nerve VII – Facial symmetry noted. Facial nerves function appears within normal limits. Cranial Nerve VIII – Normal hearing functioned noted with hearing soft spoken words as well as normal conversation. Cranial Nerve IX and X – The patient has a positive gag reflex as well as normal appearing uvula and soft palate. Cranial Nerve XI – The sternocleidomastoid and trapezius muscles are symmetric. Neck and head with full range of motion. Shoulder shrug showing trapezius muscle equal bilaterally. Cranial Nerve XII – The patient’s speech is within normal limits with a midline tongue. No sores, lesions, or abnormalities of tongue noted. | Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland):Face is symmetric.
Trachea is midline. Lymph nodes within normal limits with no goiter noted. The patient has full range of motion to head and neck. The patient’s head is without nodules noted. The patient has strong carotid pulses present bilaterally. | Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus): Patient is 20/20 in bilateral eyes with corrective lenses. Extraocular movements are intact. No nystagimus or strabismus noted. Pupils are equal, round, and reactive to light and accommodation. No drainage or redness noted to bilateral eyes. Conjunctiva are pink, sclera white without redness noted. | Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity):The patient’s ears are symmetric. The patient has a dressing to right ear from recent skin cancer removal. Incision clear without redness or drainage. The patient’s hearing within normal limits. Bilateral tympanic membranes intact and pearly gray with normal light reflex. No perforations noted. Ear canal free of drainage. | Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat):The patient’s nose is symmetric with no nasal drainage noted. Nasal septum midline. The patient denies tenderness of the external nares. Nasal mucosa is pink and within normal limits. Nares patent. No nasal flaring noted. Mouth within normal limits with no sores or blisters noted to tongue. Tongue is midline. Tonsils are pink with no swelling noted. The patient has no dental caries noted, but several fillings noted. | Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach self-examination techniques):The patient’s skin with no dryness, rashes, or acne noted.
The patient has a scar noted to his nose, right ear, and left cheek. The patient states this is areas of skin cancer that have been removed. Skin turgor within normal limits with no tenting. The patient’s hair is thin with no signs of dandruff. The patient’s nails are not brittle. No clubbing noted. Capillary refill is less than three seconds. | Breasts and Axilla (deferred for purpose of class assignment)| Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps):The patient has no swelling noted to upper or lower extremities. Skin color within normal limits with no discoloration. Peripheral pulses are strong and equal bilaterally. The patient’s legs are without varicosities. | Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any extra heart sounds, murmur):The patient’s blood pressure is 128/78, pulse 68. Upon auscultation, the apical pulse is also 68 with regular rate and rhythm. No murmur or arrhythmia noted. S1 and S2 noted without murmur. No bruit noted.
No jugular vein distention noted. | Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds):The patient’s chest has equal and bilateral rise and fall with good muscle tone. The patient denies chest tenderness upon palpation. Respiratory rate 17 breaths per minute and regular. Tactile fremitus symmetrical over posterior lung area of the back. Lungs sounds clear in all four lobes. | Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion):The patient has no curvature noted to spine. The spine is without swelling or deformity. The patient denies cervical tenderness or pain. The patient’s shoulders are symmetric with full range of motion. The patient’s elbows are free of deformity with full range of motion. The patient denies pain to elbows. The patient’s wrist are free of deformity with full range of motion. The patient denies pain to wrists. The patient’s hands are free of deformity with full range of motion. The patient denies pain to hands. The patient has healed scars from bilateral carpal tunnel surgery. The patient’s hips are symmetric with full range of motion.
The patient denies pain to hips. The patient’s knees are symmetric with full range of motion. No masses or deformities noted. The patient denies pain to knees. The patient’s knees are symmetric without obvious masses. The patient has full range of motion to bilateral knees. The patient denies pain to bilateral knees. The patient’s feet are without swelling. The patient has full range of motion to ankle and foot. No obvious deformities or masses noted. Skin is intact to bilateral feet. (Jarvis, 2012).| Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness):The patient’s abdomen is symmetric, soft, and round. The patient has normal hair distribution with skin pink. The patient denies tenderness to all four quadrants. Bowel sounds normoactive x4 quadrants. No masses palpated. Liver palpates within normal limits. | Genitourinary System (deferred for purpose of this class)| FHP Assessment|
Cognitive-Perceptual Pattern:The patient has no cognitive defects noted. | Nutritional-Metabolic Pattern:The patient states he eats breakfast, lunch, and dinner. The patient states he tries to watch what he eats. He does however state he has a weakness for ice cream. | Sexuality-Reproductive Pattern:The patient states he has been married to his wife for 28 years. He denies problems or issues with his sex life and states he is satisfied. | Pattern of EliminationThe patient states he has a regular bowel movement daily. The patient denies problems with diarrhea or constipation. The patient denies any problems with urination. The patient denies waking at night to urinate. | Pattern of Activity and Exercise:The patient states since retirement, he has slacked on his daily exercise. The patient states the only exercise he gets is daily yard work and gardening. The patient states he used to take a mile long walk, but has slacked off of that. | Pattern of Sleep and Rest:The patient states he gets 7 hours of sleep nightly.
The patient denies waking throughout the night. | Pattern of Self-Perception and Self-Concept:The patient presents as a confident male who has continuous eye contact. | Summarize Your Findings(Use format that provides logical progression of assessment.)| Situation (reason for seeking care, patient statements):The patient presents today for a recheck of his healing incision to right ear status post removal of skin cancer. | Background (health and family history, recent observations):The patient states he has a history of several skin cancer spots that have been previously removed. The patient states his mother passed away from lung cancer and his father with brain cancer. The patient denies drainage or surrounding redness to area. The patient states he applied antibiotic ointment as well as a dressing twice daily. | Assessment (assessment of health state or problems, nursing diagnosis):The patient has a healing incision noted to right ear. This incision is free of drainage or redness. Nursing Diagnosis: Risk for infection related to incision to right ear (Gulanick & Myers, 2007). | Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education):The patient needs to continue to apply the antibiotic ointment as well as dressing to the ear twice daily. The patient needs to continue to observe the area for drainage, redness, or signs of infection. The patient needs to continue to inspect his skin for areas that may be suspicious for additional skin cancer lesions. The patient is educated on proper hand-washing skills as well as signs of fever or illness. The patient is also educated on the importance of follow up with his dermatologist. | *
Gulanick, M., & Myers, J. (2007). Nursing care plans: Diagnosis, interventions, and outcomes. (6th ed.). St. Louis, Missouri: Elsevier Mosby.
Jarvis, C. (2012). Physical Examination & Health Assessment (6th ed.). St. Louis, Missouri: Elsevier Saunders.
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