D222 Vital Signs Assessment and Notes for Nursing Practice
Student Name
Western Governors University
D222 Comprehensive Health Assessment
Prof. Name
Date
Introduce Yourself
What is your name?
The patient introduced herself by name, confirming her identity for the assessment process.
What is your date of birth?
The patient stated her date of birth accurately and appeared aware of her age and related health context.
Where are you currently located?
The patient confirmed her current location, demonstrating spatial orientation and situational awareness.
What is today’s date?
The patient correctly identified today’s date, showing intact cognitive and temporal orientation.
Do you have any medical conditions or are you currently taking any medications?
The patient reported no current medical conditions and denied taking any prescribed or over-the-counter medications at this time.
Do you understand why you are here today?
The patient verbalized understanding of the purpose of the visit, indicating she was present for a routine physical and health assessment.
Observation:
The patient was alert and oriented to person, place, time, and situation (A&O ×4), indicating normal cognitive functioning.
General Assessment of Appetite and Appearance
How has your appetite been recently?
The patient reported maintaining a healthy appetite without recent changes.
Do you feel you are eating well?
The patient stated she is eating well and consuming balanced meals throughout the day.
Clinical Observation:
The patient was seated upright and displayed no signs of physical deformity or mobility limitation. Facial expressions matched the conversation context, reflecting appropriate affect and mood. Speech was articulate and coherent, with no evidence of hearing difficulty. Hygiene and grooming were excellent, and attire was clean and appropriate for the 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 appropriate |
Skin Assessment (Bilateral)
| Parameter | Observation |
|---|---|
| Color/Pigmentation | No discoloration observed |
| Temperature | Skin warm to touch |
| Moisture | Normal skin moisture noted |
| Texture | Smooth and even |
| Turgor | Normal; no tenting present |
Head and Face Examination
Palpation of the scalp, hair, and skull revealed no abnormalities. The cranial nerve VII (facial nerve) function was tested by asking the patient to stick out her tongue; a normal midline response was observed, indicating intact neuromuscular control.
Eyes, Ears, Nose, Mouth/Throat, and Neck
| Structure | Assessment Details |
|---|---|
| Eyes | Cornea and sclera were clear; eyelids normal. Pupils were equal, round, and reactive to light and accommodation (PERRLA). Extraocular movements intact, and visual fields full by confrontation. |
| Ears | External ears intact without lesions or discharge. The patient denied pain, tinnitus, vertigo, or hearing loss. |
| Nose | Nasal structure symmetrical with clear passages bilaterally. No discharge or obstruction. |
| Mouth/Throat | Lips, mucosa, and gums moist, pink, and free of lesions. Teeth intact without caries. Tongue midline; uvula central and mobile upon phonation. |
| Neck | Carotid pulses palpable and equal bilaterally. Trachea midline with full range of motion (ROM). No lymphadenopathy or thyroid enlargement. |
Chest/Thorax, Heart, and Upper Extremities
Posterior Chest
Thoracic symmetry and shape were normal. Chest expansion was equal bilaterally. Tactile fremitus, assessed using the phrase “99,” showed no abnormal vibrations, tenderness, or crepitus.
Auscultation across six lung fields revealed clear breath sounds bilaterally. Costovertebral angle tenderness was absent.
Question: Do you experience any shortness of breath?
Response: The patient denied experiencing any dyspnea or breathing difficulty.
Anterior Chest and Heart Examination
| Parameter | Observation |
|---|---|
| Apical Pulse | Palpable at 5th intercostal space, midclavicular line; brisk and regular |
| Heart Rate | Measured for 60 seconds; within normal range |
| Heart Sounds | Auscultation of all five cardiac landmarks revealed no murmurs or extra heart sounds |
Question: Do you have any chest pain?
Response: The patient denied experiencing chest pain or pressure.
Upper Extremities
Full range of motion was present with normal muscle strength. Capillary refill in fingers was less than three seconds. Radial and brachial pulses were palpable, strong, and symmetrical (+2 to +3).
Jugular Vein, Abdomen, and Lower Extremities
| Area | Assessment Findings |
|---|---|
| Jugular Vein | No distention; vein visible 1 cm above sternal angle |
| Abdomen | Flat, symmetrical; umbilicus midline; no visible pulsations |
| Bowel Sounds | Active in all quadrants |
| Percussion | Tympanic sounds; no tenderness or masses |
| Palpation | Soft abdomen; no pain or guarding |
Lower Extremities (Bilateral, Supine):
Both legs were symmetrical, with normal skin temperature and hair distribution. No edema or cyanosis observed. Toenail capillary refill was under three seconds. Peripheral pulses (femoral, popliteal, posterior tibial, dorsalis pedis) were strong and equal bilaterally. Full range of motion was noted in hips, knees, and ankles.
Neuromuscular Examination
| Test | Findings |
|---|---|
| Deep Tendon Reflexes | Normal reflexes (+2) observed 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 denied any pain or discomfort.
Health Promotion and Conclusion
Two primary health promotion strategies were discussed with the patient:
- Caffeine Reduction:
The patient currently consumes approximately 6–8 cups of coffee daily. A gradual reduction plan was recommended to lower intake and increase water consumption to 64–120 ounces per day for improved hydration and cardiovascular health. - Physical Activity:
Given the patient’s sedentary lifestyle, an exercise plan was advised, beginning with moderate walking (2,000–5,000 steps daily). The goal is to enhance circulation, aid digestion, and minimize the risk of chronic conditions such as venous stasis or thrombosis.
The patient’s questions were addressed comprehensively. She expressed understanding and willingness to follow the health recommendations. The assessment concluded with appreciation for her active participation.
References
Bickley, L. S. (2020). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.
D222 Vital Signs Assessment and Notes for Nursing Practice
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.