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

Comprehensive Head-to-Toe Assessment Transcript

Student Name

Capella University

NURS FPX 4015

Prof. Name

Submission Date

Marco Mancini – Physical Assessment Transcript

Nurse: Good morning, Mr. Mancini. My name is _________. Your physical assessment will be done by me today, head-to-toe. I know that you were experiencing certain problems with sleep and anxiety. Is it all right before we start the assessment?

Client: Yes, that’s fine.

Nurse (professional demeanor): Thank you. When you are doing the exam, all you have to do is tell me whether you feel uncomfortable or need to have a break. To begin with, we are going to measure 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 a known hypertension diagnosis.

General Appearance

Mr. Mancini looks his mentioned age, well-dressed and groomed. He has clear eye contact, yet appears to be somewhat nervous. His speech is smooth and appropriate; however, in some cases, he stops speaking about emotionally sensitive issues.

Nurse: I can see you’re a bit tense. You are doing better- thanks to you being open.

Neurological & Cognitive Status

• Level of Consciousness: Alert and oriented ×4 (person, place, time, situation)
• Cognition: Mild difficulty concentrating when answering emotionally triggering 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: Can you count backward from 100 by sevens?

Client: 93… 86… 79… umm… 72…

Note: Slowed processing noted, but appropriate effort and accuracy maintained.

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

• Head: Normocephalic, atraumatic
• Eyes: PERRLA, no nystagmus
• Ears: Tympanic membranes are 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

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

• Affect: Constricted but appropriate
• Thought processes: Logical and goal-directed
• Insight/Judgment: Fair
• Suicidal ideation: Denies current or past SI/HI
• Sleep: Difficulty sleeping due to nightmares and flashbacks
• Coping mechanisms: Avoidance (e.g., violence in media), isolation

Nurse: Thank you, Marco, thank you. It is very important that we are aware of how these memories have impacted our daily lives. You are not alone, and we are there to assist you in getting through your healing.

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)
• Schedule follow-up with Psychiatric NP in three weeks

Closing Statement

Nurse: Thank you again, Marco. Today, you will be open to us and assist us in developing a powerful care plan. You are doing well, and we will keep on collaborating to help you recover. We will call you again next week to have another therapy session and in three weeks to review the medication.

For the 2nd assessment of this class visit: Nurs Fpx 4015 Assessment 2