I will attach the last document you did for me regarding this assignment and all you will need to do is just ADD ON to the paper with this new information below. The last paper was subjective data… YOU WILL NOT NEED TO touch anything in those paragraphs, the new sections you will add will be objective data. Please keep previous paper as is and only ADD ON ( creating new sections for the objective data).
( THERE IS AN EXAMPLE BELOW TO HELP ASSIST IN WRITING THE OBJECTIVE DATA properly)
a. Physical Examination: Objective Data
1)
a) HEENT (head, eyes, ears, nose, and throat)
b) Neck (including thyroid and lymph chains)
c) Respiratory system
d) Cardiovascular system
2)
a) Neurological system
b) Gastrointestinal system
c) Musculoskeletal system
d) Peripheral vascular system
b. Needs Assessment (2 paragraphs )
1) Based on the health history and physical examination findings, determine at least two health education needs for the individual. Remember, you may identify an educational topic that is focused on wellness.
2) Support the identified health teaching needs selected with evidence from two current, peer-reviewed journal articles.
3) Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education.
4) Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) effect proposed teaching.
c. Reflection (10 points/10% [1 paragraph])
Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this complete health history and physical assessment.
1) Reflect on your interaction with the interviewee holistically.
a) Describe the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.
2) How did your interaction compare to what you have learned?
3) What barriers to communication did you experience?
a) How did you overcome them?
b) What will you do to overcome them in the future?
4) What went well with this assignment?
5) Were there unanticipated challenges during this assignment?
6) Was there information you wished you had available but did not?
7) How will you alter your approach next time?
d. Writing Style and Format (10 points/10%)
1) Writing reflects synthesis of information from prior learning applied to completion of the assignment.
2) Grammar and mechanics are free of errors.
3) Able to verbalize thoughts and reasoning clearly.
4) Use appropriate resources and ideas to support topic with APA where applicable.
5) HIPAA protocols followed.
EXAMPLE OF PHYSICAL EXAM (objective data) FINDINGS: PLEASE USE TO ASSIST IN WRITING PROPERLY for part A.
HEENT (Head, Face, Eyes, Ears, Nose, and throat)
Further inspection revealed that her skull is normocephalic, no lumps, lesions, or tenderness noted. Hair is evenly distributed, with a thin texture. No lesions or infestations are noted upon inspection and palpation. Facial features are symmetric with no facial drooping, weakness, or involuntary movements noted. Eyebrows, eyelids, and eyelashes are evenly distributed and symmetric. Sclera is white and conjunctiva is pink and moist. No signs of redness, discharge, or lesions noted. D.Y. is currently wearing contacts for vision problems. PERRLA is noted with a pupil size of 3 mm. Diagnostic positions test shows EOMs intact. The client’s external ears show that the skin is intact with no masses, lesions, or tenderness noted. The internal structures of the ears show no signs of swelling, redness, or discharge noted. The patient responds appropriately to conversation indicating the patient has no difficulties with hearing. Whispered sounds heard bilaterally. The nose is midline, symmetric, and no skin lesions noted. No deformities, inflammation, or asymmetry noted upon inspection of internal structures. Nares are patent bilaterally. No discharge noted. Lips, gums, soft palate, and buccal mucosa are pink and moist. Hard palate is white with irregular transverse rugae. Pharynx is pink and moist with no redness, lesions, or drainage noted. Teeth are all present, straight, and white in color. Tongue is smooth, pink, no lesions, protrudes in the midline, and no tremors are noted. Uvula rises in midline on phonation. Tonsils out. Gag reflex present.
Neck
Patient’s neck is supple with limited range of motion with pain and stiffness noted. No cervical lymphadenopathy or masses noted. Trachea is midline, symmetric, thyroid is not palpable, and there are no masses noted.
Respiratory System
Throughout the assessment, the patient was sitting relaxed with arms at sides, no accessory muscle use noted. Respirations were regular, even, and unlabored. Lung sounds were auscultated anteriorly and posteriorly, they were clear over the right and left lobes bilaterally. No adventitious sounds noted. Carotid pulses were palpated, 2 plus regular bilaterally. No bruits or jugular vein distention noted. No visible pulsations, heaves, or lifts noted. The heart sounds were auscultated in all 5 areas of the heart. S1 and S2 heard throughout, no extra heart sounds or murmurs noted. Apical impulse was 68 beats per minute and regular, in the 5th intercostal space at the left midclavicular line, no thrill noted. The upper extremities revealed that the brachial and radial pulses were 2 plus, regular bilaterally.
Peripheral Vascular System
Upon examination in the lower extremities, edema (2 plus non-pitting edema) was noted in the right extremity only. Both lower extremities are pink in color, without redness, cyanosis, or any skin lesions. Temperature is warm, dry, and even bilaterally. The dorsalis pedis and posterior tibialis pulses were both 2 plus, regular bilaterally. Hair distribution on both lower extremities is evenly distributed. Client reports no pain, tenderness, or warmth noted in the calf area.
Gastrointestinal System
The abdomen is rounded, symmetric, with color appropriate to genetic background. No apparent masses noted. Skin is smooth with no scars or lesions. Auscultation revealed that bowel sounds were present in all 4 quadrants. No bruits present. Light palpation revealed no masses, distention, tenderness, rigidity, pain, or guarding noted. When asked about her last bowel movement, D.Y. stated that it was this morning, brown and solid. Patient denied having any frequency or burning with urination. Reported that she goes to the bathroom very often throughout the day due to drinking lots of water. Urine is either yellow or clear colored.
Musculoskeletal System
D.Y. ambulates independently without any assistance needed with a gait that is smooth and steady. Body joints and muscles have limited range of motion. Upper and lower extremities are tender to palpation. Client reports pain in joints and muscles with movement. Muscle strength is a 3 and/or 4 in both upper and lower extremities with limited range of motion in all areas. All cranial nerves are intact. Sensory function is intact upon assessment of light touch. As previously stated, the is alert and oriented to person, place, time, and situation. She is dressed appropriately for the weather and appears clean and well groomed. Mood is cooperative, speech is clear and articulate, and behavior and language are appropriate to the conversation. Recent and remote memory is intact.
Neurological System
Patient can sense where in her face I am touching with her eyes closed, she can also open and close her jaw; cranial nerve 5 sensory and motor is intact. Patient can smile, frown, and wrinkle her forehead; cranial nerve 7 is intact. Patients’ eyes are symmetrical and proportionate to the rest of her facial features. There is no sign of any drainage, redness, or lesions. No infestations on her eyelashes or eyebrows. Her pupils are equal and round in size and they are reactive to light, and accommodation is noted. Cranial nerve 3,4,6 is intact. Patients’ ears are symmetrical and no drainage, redness, or lesions present. Palpating her external meatus there is no tenderness noted. Patients cranial 8 is intact after performing the whisper test. Patients nose is symmetrical and no sign of any deviation. No drainage, lesion or redness. Bilateral patency is intact. Patients’ lips, tounge and gums are pink, moist and intact. Patients’ uvula rises with phonation and gag reflex is present. Cranial nerve 9 and 10 are intact. Patient can say “light, tight, dynamite” with no problem, cranial never 12 is intact.
