Health Assessment Midterm

General survey

Awake, alert, and oriented x4; client appears appropriately dressed, well nourished, and groomed; mood and affect are congruent and appropriate for the situation. The client is behaving appropriately for age.

Skin

Smooth, intact, appropriately moist, uniform in thickness, and warm bilaterally. Color is even and appropriate. Skin is mobile with no tenting noted, skin recoils in less than 3 seconds when assessing turgor. No lesions, drainage, or abnormalities noted.

Hair

hair is smooth, well groomed, and evenly distributed.

Nails

smooth, uniform in thickness, firmly adhered to nail bed; color and contour are appropriate with a slight downward curve at the edges; nail bed angle is approximately 160; cap refill < 2 sec bilaterally

head and face

head is normocephalic, symmetrical, midline, and upright. Trachea is midline. No lumps or masses noted. Facial structure symmetrical and proportional. Facial movement and expressions are appropriate and symmetrical bilaterally.

Eyes

eyebrows and eyelashes are equally distributed and symmetrical. Upper eyelashes are curved up and out, bottom eyelashes are curved down and out. eyelids are intact and no drainage noted bilaterally. palpebral conjunctiva is pink and moist bilaterally. clients bulbar conjunctiva is clear and free of abnormalities bilaterally. sclera is clear and white bilaterally; iris is equally round, flat, and evenly colored bilaterally; pupils are approximately 3 mm bilaterally; equally round and reactive to light; accommodation reflex intact

Ears

External ears are symmetrical to the face and body, equal in size, and intact. Auricle is approximately aligned with the outer canthas of the eye. No discharge or lesions noted. The auditory canal is clear and free of excess cerumen or exudate. Auditory function appears intact bilaterally based on response to conversation.

Nose

External nose is symmetrical, midline, and free of any discharge or drainage. Nasal mucosa and turbinates are pink and moist without lesions or abnormal drainage. Nasal septum is midline and intact with no deviation noted. Nares are patent bilaterally

Mouth

Lips are pink, smooth, symmetrical, and appropriately moist. Teeth are intact, with good dentition. Gingiva are pink, moist, and firmly adhered to teeth without swelling. Buccal mucosa is pink, moist, and intact. Tongue is midline, symmetrical, pink, and moist, with movement intact. Hard and soft palate are intact, pink, moist, and smooth. Uvula is pink, moist, and midline. Pharynx is pink and moist with symmetrical margins. Tonsils are pink, moist, free of any lesions or localized variations, and 1+ bilaterally. Upon phonation, the uvula and soft palate rise symmetrically

Respiratory

Breathing is eupenic, even, and. non-labored. Chest has symmetrical expansion with an AP-to-lateral diameter ratio of approximately 1:2. Anterior breath sounds are clear and present bilaterallly with no adventitious sounds noted such as wheezes or crackles. Lateral breath sounds are clear and present bilaterally. Posterior breath sounds are clear and present bilaterally.

Cardiovascular

Carotid pulses 2+ bilaterally, assessed individually. Radial pulses 2+ bilaterally. Posterior tibial pulses 1+ bilaterally. Dorsalis pedis pulses 1+ bilaterally. Upon auscultation at the aortic, pulmonic, Erb’s point, tricuspid, and mitral areas, S1 and S2 are present with regular rhythm. No S3, S4, or audible murmurs noted. Findings confirmed using the diaphragm and bell of the stethoscope. Apical pulse is 75 beats/min with regular rate and rhythm.

Peripheral vascular: Bilateral lower-extremity skin is intact, with uniform coloration and evenly distributed hair. Skin is warm and dry bilaterally. Capillary refill is less than 2 seconds bilaterally. No pitting edema noted. Posterior tibial and dorsalis pedis pulses are 1+ bilaterally.