Physical Health Assessment Summary

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Register to read the introduction… on 2-12-14. Information was obtained largely from the patient, patient's wife and supplemented with assessment findings from the patient’s chart. The student nurse found the patient to be within the normal range for his age in the body systems of skin, hair, and nails, head, eyes, ears, sinuses, and nose, breast, genital. The patient also was found to be in the normal range for his age in his sleeping and rest patterns (Jarvis, …show more content…
Abnormal assessments included respiratory, cardiovascular, peripheral vascular, neurological, urinary, gastrointestinal, musculoskeletal, hematologic, and endocrine. The patient also had an abnormal dietary and eating habits. Objective data was obtained through vital signs and intake and output measurements. Assessment of blood pressures and looking at previously documented blood pressure readings in his chart led to the assumption of hypertension. His primary care physician further confirmed this as a medical diagnosis. Concerns that the student nurse would want to monitor for would be signs of decreased cardiac output and lack of blood flow to his peripheral tissues that would be evidenced by edema and relatively colder skin (Jarvis, 2008). R.M. also had weakened pedal pulses of +1 bilaterally. Another abnormal assessment was with R.M.'s musculoskeletal system. R.M. had very limited range of motion especially in his lower extremities greatly due to arthritis and a very labor intensive job his entire working life. In R.M.'s patient's chart, it stated he had functional decline and joint limitations. Additionally, neurologically, R.M. had suffered from two strokes in 2013 one on the right and left hemisphere of the brain. Porth describes a stroke as an "acute focal neurologic deficit from a vascular disorder that injures brain tissue (Porth, 2009)." The strokes were believed to …show more content…
had a very strong faith and strong family connection. He had great support from his family and grandchildren. His coping method was spiritually prayer and complete assistance from his LPN home care nurse and wife. Through this he had many outlets for stressors. Patient R.M. stated the day with prayer as one way he is able to reduce his stress and increase his hope. Both of these things are vital to decreasing healing time and increasing overall patient moral. Patient R.M's wife also stated that he wakes up early every morning to pray and regularly attended mass, but in his functional decline, a chaplain brings Eucharist to the home. R.M. also stated that just being around his grandchildren helps increase his moral and boost his hopefulness and mood. R.M. strives for a positive outlook each day with his wife by his side and noted that coping mechanisms are important to help his healing process.

Jarvis, C. (2008). Physical examination and health assessment (5th ed.) with skills DVD. St. Louis: Saunders.
Lemon, P. & Burke, K. (2011). Medical-surgical nursing (5th ed.). New Jersey: Prentice Hall.
Porth, C. (2009). Pathophysiology: Concepts of Altered Health States (8th ed.). Philadelphia: Lippincott, Williams & Wilkins.
Spark Ralph, S. & Taylor, C. M. (2011). Nursing diagnosis reference manual (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals

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