D222 Vital Signs Assessment and Notes for Nursing Practice

Student Name

Western Governors University

D222 Comprehensive Health Assessment

Prof. Name:

Date

Introduce Your Self

What is your name?
What is your date of birth?
Where are you currently located?
What is today’s date?
Do you have any medical conditions or are you currently taking any medications?
Do you understand why you are here today?

The patient is alert and oriented to person, place, time, and situation.

General Assessment of Appetite and Appearance

How has your appetite been recently?
Do you feel you are eating well?

The patient reports eating well. She is seated upright with no visible physical deformities or mobility limitations. Her facial expressions are appropriate for the context, reflecting an appropriate mood and affect. Speech is clear and appropriate, with no signs of hearing impairment. Personal hygiene is well maintained; the patient is clean, well-groomed, and dressed suitably for the setting.

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 recorded as appropriate

Skin Assessment (Bilateral)

Parameter	Observation
Color/Pigmentation	No visual abnormalities
Temperature	Skin is warm
Moisture	Skin is moist
Texture	Even skin texture
Turgor	No tenting observed

Head and Face Examination

Palpation of scalp, hair, and cranium reveals no abnormalities.
Cranial nerve VII function tested by asking the patient to stick out the tongue; normal response observed.

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

Structure	Assessment Details
Eyes	Cornea and sclera inspected; eyelids gently pulled down without abnormalities. Pupils reactive to light (PERRLA). Visual fields tested by confrontation method. Extraocular muscles tested (cranial nerves III, IV, VI).
Ears	External ears examined; no discharge or lumps detected. Subjectively, patient denies tenderness, pain, tinnitus, vertigo, or hearing loss.
Nose	External symmetry noted; no nasal drainage observed. Nares patency tested bilaterally with no obstruction.
Mouth/Throat	Lips are moist, symmetrical, and appropriately colored. Buccal mucosa moist and free of lesions. Dentition intact without caries or appliances. Gums healthy and moist with no lesions. Tongue moist, midline without deviation. Uvula midline and mobile.
Neck	Carotid pulses palpated bilaterally without difficulty. Trachea positioned midline without deviation. Active range of motion includes flexion, extension, and lateral movements without limitation.

Chest/Thorax, Heart, & Upper Extremities

Posterior Chest:

Thoracic shape and configuration are normal and symmetrical.
Symmetrical chest expansion noted.
Tactile fremitus assessed using the phrase “99” at multiple points; no tenderness or crepitus detected.
Costovertebral angles palpated; no tenderness.
Auscultation of at least six lung fields reveals clear breath sounds.

Question: Do you experience any shortness of breath?
Patient denies shortness of breath.

Anterior Chest:

Palpation and auscultation of anterior lung fields performed with no abnormal findings.

Heart:

Parameter	Observation
Apical pulse	Palpable at the midclavicular line, 5th intercostal space; brisk and tapping
Apical heart rate	Measured over 60 seconds
Heart auscultation	Five standard areas auscultated; no murmurs detected

Question: Do you have any chest pain?
Patient denies chest pain.

Upper Extremities:

Active range of motion tested in multiple directions with normal muscle strength.
Capillary refill on fingers less than 3 seconds.
Brachial and radial pulses palpated with normal strength (graded +2 to +3).

Jugular Vein, Abdomen, & Lower Extremities

Area	Assessment Findings
Jugular Vein	No jugular vein distention observed; level is 1 cm above sternal angle
Abdomen	Symmetric, flat contour with umbilicus midline; no pulsations visible
Bowel Sounds	Active in all four quadrants
Percussion	Tympanic sounds noted throughout abdomen; no tenderness reported
Palpation	No tenderness or abnormalities in light or deep palpation

Lower Extremities (Bilateral, Supine):

Symmetrical with normal skin condition, hair distribution, and temperature.
No edema present.
Toenail capillary refill less than 3 seconds.
Femoral, popliteal, posterior tibialis, and dorsalis pedis pulses all strong and symmetrical (+2 bilaterally).
Active range of motion tested for hips, knees, and ankles with normal function.

Neuromuscular Examination

Test	Findings
Deep tendon reflexes	Biceps, triceps, brachioradialis, patellar, and Achilles reflexes all normal (graded +2)
Sensory Testing (Dull/Sharp)	Face, arms, hands, legs, feet respond appropriately to stimuli with eyes closed
Spine and Coordination	Toe touch, spine range of motion, shallow knee bend, heel-to-toe walk, walking on tiptoes and heels all performed without pain or coordination difficulties

Question: Are you experiencing any pain or discomfort during these movements?
Patient denies any pain or discomfort.

Health Promotion and Conclusion

Two important health promotion recommendations were discussed with the patient:

Due to the patient’s high caffeine intake (6-8 cups of coffee daily), it is advised to gradually reduce caffeine consumption and increase daily water intake to between 64 and 120 ounces.
The patient’s sedentary lifestyle was addressed, encouraging a gradual increase in daily physical activity, aiming for 2,000 to 5,000 steps per day to support digestion and reduce risks such as blood clots.

The patient was invited to ask questions and all queries were addressed satisfactorily. The session concluded with thanks for the patient’s participation.

References

Jarvis, C. (2019). Physical Examination and Health Assessment (8th ed.). Elsevier.
Bickley, L. S. (2020). Bates’ Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer.