Physical Exam Paper

Running head:   PHYSICAL EXAMINATION (PE) WRITTEN DOCUMENTATION

Nursing 200: Complete Physical Examination (PE) Written Documentation
     
Indiana State University
College of Nursing, Health, and Human Services
Nursing 200: Complete Physical Examination (PE) Written Documentation
The format for this paper is based on : Jarvis (2008).

Examiner:      , SN ISU         Date: 4/12/09

Patient: S.C. Age: 20 Occupation: Full-time nursing student taking 14 hours       Language spoken: English
Gender: Marital Status         Race:   Caucasian
Ethnic affiliation / association:   American
Measurements (2 points):
    • Weight (in lbs & kgs) 125 lbs     56.8kgs
    • Height (in in & cm) 60 inches     15.2 cm
    • Waist-to-hip ratio .82
    • BMI 21.2   Category   normal
Vital signs (2 points):
    • Radial pulse rate 61 /min; Rhythm regular-regular
    • Respiratory rate 16 /min; Ease of respirations: easy
    • Temperature (if indicated) 98.2 degrees ; Route
    • Blood pressure
          Right arm 120 / 80 mmHg; Pt position:
          Left arm 120 / 82 mmHg; Pt position:

General Survey/Mental Status (2 points): well-nourished, well- hydrated; erect, relaxed posture; voluntary, coordinated movements; appears stated age, dress appropriate for age and gender; well-groomed; A/O x3; relaxed expressions, speech clear, articulate, word choice clear, understandable; affect matches stated mood; attentive; college level reading and writing, logical judgment, thought process consistent and realistic; denies suicidal ideation.

Skin, Hair, & Nails (3 points): Skin pinkish tan, light pigmentation, warm and dry; texture smooth and firm, uniform, mobile, immediate recoil when pinched; no vascularity, bruising, lesions;
Hair brown; texture thick, curly; evenly distributed, fully covers scalp; clean with no lesions,bruising.
Nails clean, edges smooth and rounded; uniform thickness, smooth, regular, no clubbing, no sponginess; even distribution; nail pink,... [continues]

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