Sample Nursing Health Assessment Report

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NURSING ASSESSMENT PART 4
Name: Adina Perlow
Date: April 18, 2018
Continue your Nursing Health Assessment. Please include rational for assessment techniques. (why do you assess a certain way and what findings are you looking for).

Cardiovascular Assessment:
• Inspect and Palpate for Pulsations on Chest and at PMI (state what and where the PMI is located), describe.
Rationale:

o The point of maximal impulse, is the location at which the cardiac impulse can be best palpated on the chest wall. o It is located at the fifth intercostal space at the midclavicular line. o Abnormalities that are being examined includes some arrhythmias, such as premature ventricular contraction or atrial fibrillation.
Assessment:
o K.O laid on his left side …show more content…

Assessment: o K.O. Rate and rhythm was 80 beats per min, which was consistent with his radial pulse. o No abnormal dysrhythmia o Apical pulse was normal and expected with a grade of 3.

• Palpate all pulse sites bilaterally. Where are they located? (2). Describe pulse in terms of rhythm & strength or grade(1).Assess carotid artery appropriately (1).

Rationale: o Assessing the pulse is direct indicator that the circulatory system has a continuous flow of blood. o Feeling the pulse indicates means we are feeling successive contractions of the heart.

Assessment:
Pulse Location Rhythm Strength
Carotid artery
(One at a time) located along the medical edge of the sternocleidomastoid muscle in the neck. No dysrhythmia 4
Brachial pulse groove between biceps and triceps at antecubital fossa No dysrhythmia 3
Radial thumb side of forearm at wrist No dysrhythmia 4
Femoral below the inguinal ligament, midways between symphysis pubis and anterior superior iliac spin No dysrhythmia 3
Popliteal behind the knee No dysrhythmia …show more content…

No dysrhythmia 3

• Palpate temperature of extremities and describe.

Rationale: o We palpate the skin for temperature, moisture, texture turgor, tenderness, distention or masses.
Assessment
o Arms are equal in size, no swelling, pinkish skin tone, no clubbing of finger tips, warm bilaterally. o No observed lesions or cuts o Legs are pink in color from toes bilaterally, normal distribution of hair, no ulcers, warm bilaterally. o No observed lesions or cuts

• Inspect and palpate extremities for edema and capillary refill, compare both sides.
Rationale:
o We look for capillary refill to monitor dehydration and amount of blood flow to the tissue. o For a normal capillary refill, a pink color should return 3 seconds after pressure is removed. o We look for edema by examining areas of the skin that is swollen or edematous from a buildup of fluid in the tissues.
Assessment:
o Finger capillary refill time less than 2 seconds, bilaterally o No edema present in bilateral arms o Toe capillary refill time less than 2 seconds, bilaterally o Slight edema present on right ankle
 Non- pitting edema
 Tender
 Pain 2/10, pain has been on and off for 2

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