Module 11 Content: You Completed Your Full Head-To-Toe Asses ✓ Solved

Module 11 Contentyou Completed Your Full Head To Toe Assessment Skills

Document your full head-to-toe assessment results, focusing solely on objective findings without bias or interpretation. Clearly state if an assessment finding is nonpalpable or if sounds are not heard, such as "no bowel sounds heard," unless a full five-minute listening was performed. Be concise but descriptive when necessary, ensuring accurate and precise documentation of each assessment parameter as observed during the skills demonstration.

Sample Paper For Above instruction

Patient Name: Jane Doe

Date of Assessment: October 25, 2023

Head and Face: Skin of the scalp and face appears intact, dry, without lesions or abnormalities. No facial asymmetry or swelling noted. Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. No facial drooping or tremors observed. Mouth and oropharynx: oral mucosa moist, lips intact, no lesions or sores present. Teeth are aligned; absence of oral lesions.

Neck: Palpation reveals no lymphadenopathy or thyroid enlargement. Trachea midline. Neck muscles symmetric, no tenderness or stiffness reported or observed. Carotid arteries auscultated for bruits; no bruits heard bilaterally. Jugular venous distention absent.

Chest and Lungs: Inspection shows symmetric chest expansion. Auscultation reveals normal breath sounds bilaterally; no adventitious sounds such as crackles, wheezes, or rhonchi. No tenderness upon palpation of the thorax.

Heart: Precordium: palpation notes a regular heartbeat, no palpable thrills. Auscultation confirms regular rate and rhythm, normal S1 and S2 sounds, no murmurs or extra sounds heard.

Breasts: Skin of breast tissue intact, without lumps, discoloration, or abnormal abnormalities. No tenderness or unusual findings on palpation.

Abdomen: Inspection shows flat abdomen, no visible distention or scars. Auscultation reveals bowel sounds present and active in all quadrants, with normal rhythm. Palpation: no tenderness, masses, or organomegaly detected. No rebound or guarding noted.

Extremities: Range of motion of arms and legs full and symmetric. No swelling, deformities, or discoloration observed. Palpation: pulses palpable and symmetrical at all extremities; pedal pulses rated 2+ bilaterally. No edema or clubbing noted.

Neurological: Sensory examination intact to light touch and pinprick in all extremities. Cranial nerves grossly intact; no deficits observed. Motor strength 5/5 in all extremities. Reflexes: patellar and Achilles reflexes 2+ bilaterally, symmetric.

Skin: Properly moisturized, intact, without rashes, lesions, or textures changes. No cyanosis, pallor, or jaundice observed.

References

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