Fundamentals Of Nursing Assessment Paper

In Fundamentals of Nursing, by Perry (2013), nursing assessment is defined by “the deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns.” A comprehensive assessment includes not only data collection about the client, but interpretation of data to target key variances in the client’s wellbeing. Physical assessment as well as information about the patient’s psychiatric health, spiritual health, and demographics of support are all parts of a complete data set. After the initial assessment, the information is interpreted to formulate a care plan with a problem, goal, and list of interventions. Care plans, when combined with active participation

Her facial expressions are consistent with her chronological age. There are no abnormal hair distributions. No lymph nodes are palpable. She has no tenderness with sinus palpation. Her eyes are symmetrical with full mobility. Conjunctiva are white. She has no periorbital edema. With her glasses, she has 20/20 vision bilaterally. Without her glasses, she has 20/40 vision in the right eye and 20/60 vision in the left eye. She has positive PERRLA. There is no ear drainage, itching or pain. The nose is symmetrical and septum is intact. She has no nasal congestion. She has no nosebleed, mouth sore, or dental pain. Her mucosal membranes are pink and moist. She has no retraction of the gingivae. The tongue is ink and moist, midline with full mobility. Her tonsils have been removed. The neck is symmetrical and midline. She displays no dysphagia. Her respiratory rhythm is eupneic, with a rate of twenty respirations per minute. She has a AP ratio of 1:2 with no spinal deformities. Her breaths are regular, easy, and unlabored with no accessory muscle use. There is no dullness upon percussion through all lung fields. Her lungs are clear through all