Chamberlain College of Nursing NR509 Advanced Physical Assessment.

Document Content and Description Below

Student Name: ______________________________________________ *This form should be used by students to practice as they rotate through the corresponding immersion stations. While the subjective asses... sment portion of this case is not included in the final immersion evaluation, students should be able to collect and assimilate pertinent patient history data as they prepare to start their practicum courses. Most of the physical examination techniques will be included in the final head to toe immersion evaluation. Those parts that are not included are highlighted in bold letters. The exact immersion exam steps, that will need to be completed for immersion evaluation purposes, are contained in the NR509 Immersion Physical Examination Study Guide. Generalized Abdominal Pain Patient Information Olivia, a 25 year-old female, comes to the clinic presenting with a chief concern of abdominal pain. The abdominal pain is generalized in location, and described as a dull pain, non-radiating. She notes some acid reflex, and reports she has a history of gastritis. She also notes decreased appetite recently. Denies any nausea or vomiting, denies any recent bowel changes. Denies current sexual activity, denies alcohol use or smoking. LMP was 2 week ago. This study resource was shared via CourseHero.comChamberlain College of Nursing NR509 Advanced Physical Assessment EPISODIC SUBJECTIVE ASSESSMENT / GENERALIZED ABDOMINAL PAIN (Patient history is not included in the final immersion evaluation) INTRODUCTION _____1. Introduces self as NP student _____2. Acknowledges purpose of exam _____3. Asks open-ended questions to begin and narrows down to closed ended questions _____4. Asks questions in an appropriate, professional, manner CC / HPI _____1. Includes the following:  Onset  Location  Duration/Timing  Characteristics/Quality/Severity  Aggravating factors/Associated Symptoms  Relieving factors  Treatment/Medications/Remedies PMH _____1. Major childhood illnesses _____5. Immunizations _____2. Major adult illnesses _____6. Allergies to medications, foods and environment _____3. Surgeries _____7. Medications (including RX, OTC, herbal) _____4. Hospitalizations FAMILY HISTORY _____1. Asks about both parents _____2. Siblings SOCIAL HISTORY _____1. Occupation _____2. Relationship status _____3. Children HABITS _____1. Tobacco _____2. ETOH /Illegal Drug Use ROS _____1. Constitutional ______4. GI _____2. HEENT ______5. GU _____3. Cardiovascular/Lungs Sub-total History Items Correct ______/24 This study resource was shared via CourseHero.comChamberlain College of Nursing NR509 Advanced Physical Assessment EPISODIC PHYSICAL EXAMINATION (Items in bold are not included in the final immersion evaluation) EARS, NOSE SINUSES, MOUTH, AND PHARYNX ____1. Otoscopic examination of ears ____2. Examines mouth and throat CHEST/PULMONARY/CARDIOVASCULAR _____1. Auscultates breath sounds anterior and posterior lung fields _____2. Auscultates heart sounds in all 5 areas with diaphragm and bell ABDOMEN _____1. Inspects abdomen with full exposure all quadrants. Note contour, symmetry, umbilicus, skin, pulsation or movement _____2. Auscultates for bowel and vascular sounds in all quadrants _____3. Percusses in all quadrants of abdomen including percussing over liver and spleen _____4. Palpates lightly all quadrants _____5. Palpates deeply all quadrants _____6. Checks specifically for liver and spleen enlargement _____7. Perform Iliopsoas Muscle Test _____8. Perform Murphy Sign _____9. Perform Blumberg Sign BACK _____1. Percuss for Costovertebral Angle Tenderness Sub-total Physical Exam Items Correct: ______/14 Student Comments: This study resource was shared via CourseHero.com Powered by TCPDF (www.tcpdf.org) [Show More]

Last updated: 2 years ago

Preview 1 out of 3 pages