NURS FPX 4015 Assessment 1 Comprehensive Head-to-Toe Assessment Transcript

Student name

Capella University

NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care

Professor Name

Submission Date

Marco Mancini – Physical Assessment Transcript

Nurse: Well, good morning, Mr. Mancini. My name is Shazia. Today I will be doing your head to toe physical examination. I know you have been experiencing certain sleeping problems and anxiety. Would it be alright to go ahead with the assessment before we start?

Client: Yes, that’s fine.

Nurse (professional demeanor): You are welcome. During the exam, be able to inform me that you are not comfortable or have to rest. We shall start with measuring your vital signs.

[Vital Signs – Objective]

• Temperature:6°F
• Heart Rate: 82 bpm, regular rhythm
• Respiratory Rate: 16 breaths/min, unlabored
• Blood Pressure: 148/92 mmHg
• O2 Saturation: 98% on room air
• Height: 5’10”
• Weight: 175 lbs
• BMI:1 (normal range)

Note: Elevated BP is consistent with known hypertension diagnosis.

General Appearance

Mr. Mancini is of the correct age, dressed and groomed well. He has a good eye contact and appears to be a bit nervous. His speech is clear though there are times that he stops speaking when talking on emotionally sensitive issues.

Nurse: I can notice that you are tense. You are feeling good–you are very open.

Neurological & Cognitive Status

• Level of Consciousness: Alert and oriented ×4 (person, place, time, situation)
• Cognition: Mild impairment in concentration in responding to emotionally evoking questions.
• Memory: Intact short- and long-term recall.
• Cranial Nerves II–XII: Grossly intact (CN VII facial symmetry observed during conversation; CN II gross visual acuity normal).

Nurse: Are you able to count backwards by sevens starting with 100?

Client: 93… 86… 79… umm… 72…

Note: Processing slowed, however, proper effort and accuracy were observed.

Head, Eyes, Ears, Nose, Throat (HEENT)

• Head: Normocephalic, atraumatic
• Eyes: PERRLA, no nystagmus
• Ears: Tympanic membranes clear bilaterally
• Nose: Mucosa pink, no congestion
• Mouth/Throat: Moist mucous membranes, no lesions, dentition intact

Skin

• Color: Normal for ethnicity
• Temperature: Warm, dry
• Turgor: Good elasticity
• Lesions: No rashes, ulcers, or abnormal findings
• Psychomotor activity: No apparent self-harm, scarring.

Cardiovascular

• Heart sounds: S1 and S2 audible, no murmurs
• Rate & rhythm: Regular
• Peripheral pulses: 2+ bilaterally
• Capillary refill: <2 seconds

Respiratory

• Breath sounds: Clear to auscultation bilaterally
• Respiratory effort: Non-labored, even pattern
• Chest expansion: Symmetrical

Gastrointestinal

• Abdomen: Flat, soft, non-tender
• Bowel sounds: Present in all four quadrants
• No hepatosplenomegaly
• Reports no recent nausea, vomiting, or changes in appetite

Genitourinary

Subjective only as per outpatient exam protocol.

• Denies dysuria, hematuria, or frequency
• Denies sexual dysfunction
• No history of STIs reported

Musculoskeletal

• Gait: Steady
• ROM: Full range in upper/lower extremities
• Muscle strength: 5/5 bilaterally
• No joint swelling or tenderness

Psychiatric/Mental Health Observations

• Mood: “Some days I feel guilty… I get scared easily.”
• Affect: Constricted but appropriate
• Thought processes: Logical and goal-directed
• Insight/Judgment: Fair
• Suicidal ideation: Denies current or past SI/HI
• Sleep: Problems in sleeping because of nightmares and flashbacks.
• Coping mechanisms: Avoidance (e.g., violence in media), isolation

Nurse: I am glad you told me, Marco. It is quite essential that we know how these memories affect your life in daily living. You are not the only one and we are to assist in your recovery process.

Plan of Care – Immediate Follow-Up

• Continue lisinopril for hypertension
• Citalopram 20 mg for depression/anxiety
• Prazosin 1 mg qHS for nightmares
• Monitor for orthostatic hypotension due to medication interaction
• Referral to individual psychotherapy (CBT)
• Psychoeducation on PTSD, medication side effects, and suicide prevention resources
• Schedule follow-up with Psychiatric NP in three weeks

Closing Statement

Nurse: Thank you again, Marco. Today you are open, and this will assist us in constructing a robust care plan. You are improving, and you will not stop collaborating with us in order to achieve your recovery. We will follow up with you in a week and three weeks to have a therapy session and medication follow-up, respectively.