D222 Vital Signs Assessment and Notes for Nursing Practice

D222 Vital Signs Assessment and Notes for Nursing Practice

Student Name

Western Governors University 

D222 Comprehensive Health Assessment

Prof. Name

Date

D222 Vital Signs Assessment and Notes for Nursing Practice

Introduce Yourself

What is your name?

The patient introduced herself by name, confirming her identity, which is essential for ensuring accurate and personalized care throughout the assessment.

What is your date of birth?

She provided her date of birth correctly and appeared fully aware of her age, which helps in correlating age-related health risks and medical history.

Where are you currently located?

The patient confirmed her present location, demonstrating appropriate spatial orientation and awareness of her environment.

What is today’s date?

She accurately stated today’s date, indicating intact cognitive functioning and temporal orientation.

Do you have any medical conditions or are you currently taking any medications?

The patient reported no known medical issues and denied the use of any prescription or over-the-counter medications, suggesting no immediate pharmacological concerns.

Do you understand why you are here today?

She expressed a clear understanding of the purpose of her visit, indicating she was present for a routine physical examination and health evaluation.

Observation:
The patient was alert and oriented to person, place, time, and situation (A&O ×4), which reflects normal cognitive status and readiness for assessment.

General Assessment of Appetite and Appearance

How has your appetite been recently?

The patient reported a stable and healthy appetite without any notable changes, which is important for assessing nutritional status and overall health.

Do you feel you are eating well?

She affirmed that her diet is balanced and sufficient, which supports maintenance of adequate nutrition and energy levels.

Clinical Observation:
The patient was sitting upright comfortably, showing no signs of physical distress or deformity. Her facial expressions were congruent with the discussion, indicating a suitable mood and affect. Speech was clear and coherent, without hearing difficulties. Hygiene was impeccable, and clothing was clean and appropriate for the clinical environment.

Vital Signs and Basic Measurements

Measurement	Result/Observation
Height and Weight	To be recorded
Radial Pulse (bpm)	Measured over 30 seconds
Respiratory Rate	To be recorded
Blood Pressure (arm)	To be recorded
Pain Level	Assessed and documented as needed

Skin Assessment (Bilateral)

Parameter	Observation
Color/Pigmentation	No discoloration noted
Temperature	Skin warm to the touch
Moisture	Normal skin moisture observed
Texture	Smooth and even
Turgor	Normal with no tenting present

Head and Face Examination

Palpation of the scalp, hair, and skull did not reveal any abnormalities. Function of cranial nerve VII (facial nerve) was tested by having the patient stick out her tongue, which remained in the midline, indicating intact neuromuscular control.

Eyes, Ears, Nose, Mouth/Throat, and Neck

Structure	Assessment Details
Eyes	Clear cornea and sclera; normal eyelids; pupils equal, round, reactive to light and accommodation (PERRLA); intact extraocular movements; full visual fields by confrontation.
Ears	External ears intact with no lesions or discharge; no complaints of pain, tinnitus, vertigo, or hearing loss.
Nose	Symmetrical nasal structure; clear bilateral nasal passages; no discharge or obstruction.
Mouth/Throat	Lips, mucosa, and gums moist and pink without lesions; teeth intact without decay; tongue midline; uvula mobile and central with phonation.
Neck	Carotid pulses palpable and symmetrical; trachea midline with full range of motion; no lymphadenopathy or thyroid enlargement detected.

Chest/Thorax, Heart, and Upper Extremities

Posterior Chest

Thoracic shape and symmetry were normal, with equal chest expansion bilaterally. Tactile fremitus, assessed by asking the patient to say “99,” was normal without abnormal vibrations or tenderness. Lung auscultation across six fields revealed clear breath sounds, with no evidence of crepitus or costovertebral angle tenderness.

Question: Do you experience any shortness of breath?
Response: The patient denied any episodes of dyspnea or breathing difficulty.

Anterior Chest and Heart Examination

Parameter	Observation
Apical Pulse	Palpable at the 5th intercostal space, midclavicular line; brisk and regular.
Heart Rate	Measured for 60 seconds and found within normal limits.
Heart Sounds	Auscultation at all five cardiac landmarks revealed no murmurs or abnormal heart sounds.

Question: Do you have any chest pain?
Response: The patient denied any chest pain or pressure sensations.

Upper Extremities

The patient demonstrated full range of motion and normal muscle strength in the upper limbs. Capillary refill time was under three seconds, indicating good peripheral perfusion. Radial and brachial pulses were strong, symmetrical, and rated between +2 to +3.

Jugular Vein, Abdomen, and Lower Extremities

Area	Assessment Findings
Jugular Vein	No distention; visible approximately 1 cm above the sternal angle.
Abdomen	Flat and symmetrical with a midline umbilicus; no visible pulsations.
Bowel Sounds	Active in all four quadrants.
Percussion	Tympanic sounds; no tenderness or masses detected.
Palpation	Abdomen soft with no signs of pain or guarding.

Lower Extremities (Bilateral, Supine):
Both legs were symmetrical, with normal skin temperature and hair distribution. No edema or cyanosis was observed. Toenail capillary refill was less than three seconds. Peripheral pulses—including femoral, popliteal, posterior tibial, and dorsalis pedis—were strong and equal bilaterally. Full range of motion was evident in hips, knees, and ankles.

Neuromuscular Examination

Test	Findings
Deep Tendon Reflexes	Normal reflexes (+2) bilaterally in biceps, triceps, brachioradialis, patellar, and Achilles tendons.
Sensory Testing	Normal responses to dull and sharp stimuli with eyes closed.
Spine and Coordination	Full spinal range of motion; able to perform heel-to-toe walk, tiptoe walk, and shallow knee bends without pain or imbalance.

Question: Are you experiencing any pain or discomfort during these movements?
Response: The patient reported no pain or discomfort during the neuromuscular tests.

Health Promotion and Conclusion

Two important health promotion strategies were discussed to enhance the patient’s wellbeing:

1. Caffeine Reduction:
   The patient currently consumes between 6 and 8 cups of coffee daily. A gradual plan to reduce caffeine intake was recommended, along with increasing water consumption to approximately 64–120 ounces daily. This strategy supports improved hydration and cardiovascular health.

2. Physical Activity:
   Given her predominantly sedentary lifestyle, an exercise regimen starting with moderate walking—targeting 2,000 to 5,000 steps daily—was advised. Increasing physical activity can promote better circulation, aid digestion, and reduce risks of chronic conditions such as venous stasis or thrombosis.

The patient’s questions were addressed thoroughly, and she demonstrated understanding and willingness to adhere to these health recommendations. The assessment ended with recognition and appreciation of her active involvement in the process.

References

Bickley, L. S. (2020). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Jarvis, C. (2019). Physical examination and health assessment (8th ed.). Elsevier.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). Elsevier.