palpation, auscultation, inspection and percussion
My assessment of Mrs Jay from head to toe included palpation, auscultation, inspection and percussion of her entire body system. I started by conducting hand hygiene. I also assessed her level of consciousness, which showed that Mrs Jay was alert to situation, time, person and place. Her eyes’ pupils were similar, had a rounded shape, and reacted to accommodation and light. She didn’t exhibit any allergies. I also asked her to weigh her pain from zero (no pain) to ten (worst pain). She denied having any pains within her body. Her physical appearance was appropriate for her condition. The structure of her body, her behaviour and physical presence were suitable for the interview, and she was cooperative throughout the assessment.
The other assessment was on Mrs Jay’s vital signs. Here, I began by assessing her pulse through radial palpation of pulse. The observed pulse rate was 80 beats every minute. On determining her rate of respiration, I found out that she had 18 breath in one minute, and she had normal blood pressure ranging at about 129/82. Her body temperature was at 98.8. Unfortunately, I couldn’t assess her level of oxygen because I didn’t have the necessary equipment. However, assessment on her vital signs showed that her body system was at reasonable limits. I moved on to look at the condition of her nails and skin. Her nails were round, smooth and pink in colour, but I did not note any clubbing. Besides, I established that her refill of the capillary was below three seconds. Bilaterally touching her skin, I recognized that it was dry and warm. She had good skin turgor. I did not note any tenting after pinching on her collarbone.
Further, I inspected her face and head and noted that her skin was in the required condition. She had symmetrical facial structure, and distribution of colour on her skin was normal. I then palpated and inspected her skull, neck, scalp and hair. I noticed she had a norm cephalic head, centred at the middle, and it had no lesions or lumps. Her hair was distributed evenly on the skull, and she didn’t show any signs of infestation. Upon palpation of Mrs Jay’s lymph nodes, I didn’t identify any sign of lymphadenopathy. This palpation included postauricular, preauricular, submental, deep, posterior, supraclavicular, occipital, submandibular, superficial and jugoldiagtric. I asked Mrs Jay to move her head from side to side, up and down. Her neck muscles were symmetrically bilateral, her neck and head were in full motion, her trachea was at the midline, and her shoulders did not resist the movement. I did not see any masses or pulsation, showing that her cranial nerve was remarkably intact.
The next assessment was on Mrs Jay’s ears, and eyes and I noted that her eyes were bilaterally symmetrical. I did not see any discharge or lesions. On the eyebrows, eyelids and eyelashes, I did not find manifestations. The eye’s outer lined up on the top of her ears. She had a white sclera and oink conjunction. I then tested her accommodation. I asked her to follow a penlight at a distance, from the position of her head to the part between her noses. The two pupils of Mrs Jay’s eyes were similar, well accommodated, rounded shape, and they reacted to light. This assessment also tested her cranial nerves, trochlear, abducens, and oculomotor. In further evaluation of the inner part of Mrs Jay’s nose, I did not see foreign bodies, nor deviated septum. Besides, she had pink lips, moist and intact with no lesions of cracks. There was no odour in her mouth, and her teeth were sparkling white and well-aligned.
I further auscultated and examined the six lung fields of Mrs Jay. Her lungs seemed to be clear, and I did not hear adventitious sounds. She had even respirations, unlabored breathing, and her accessory muscles were not in use. When I palpated the lungs, I did not find tenderness or masses, and the temperature was bilaterally dry and warm. I did this exercise two times, in the anterior chest and the posterior chest. I auscultated her five cardiac areas, including the aortic valve, tricuspid, the apical impulse, pulmonic, and the Erbs point with the use of a stethoscope. Everything was within the appropriate range. Inspection of the pulses of her jugular venous as well as carotid vibration showed normality in everything.
What followed was an inspection, percussion, palpation and auscultation of her abdomen. I also spent 2 to 5 minutes listening on every sign, and I heard bowel sounds on the four quadrants. She had a round stomach, with no foreign distensions and masses. She had intact extremities, and the lower and upper extremities were in complete motion. Mrs Jay also had dorsalis pedis in her two feet, as well as non-bounding regular rhythm. Her muscles had a lot of energy. She did not have difficulties walking on her two feet from one place to another. I also assessed her body balance using the Romberg test, whereby I asked Mrs Jay to stand still with her eyes closed.
I concluded the assessment with a re-examination of Mrs Jay’s pain. I realized that pain remained at zero. I was so appreciative to her time and giving a chance to assess her as a part of my class assignment.
Developmental Considerations
Based on the theory of Erickson, Mrs Jay is in a stage of development known as generativity versus stagnation. Mrs Jay is a successful French woman who is happy with her career occupation. She has been in a marriage for 25 years and blessed with two kids, the two of which are 22 years and above. She states that she has always been happy in life. She is contented with her life, and she is learning a new concept every day. I believe that she successfully attains the requirements of the theory of developmental stage by Erickson.
Psychosocial Considerations
Throughout the assessment, Mrs Jay says that she has no problems. However, at times when stressed, she like watching football on the television, to listen to music.
Needs Assessment
According to the health history and assessment of Mrs Jay, I gave her some details regarding heart attack, based on the information on the Heart Disease Prevention website, because his biological father had died of a heart attack many years ago (Heart Disease Prevention). I wanted to make sure that she is well informed about heart diseases and how she can prevent herself from suffering from such conditions. I gave her advice on the type of foods that to take, especially those that are rich in iron to help her in Hemochromatosis. I asked her to read more from the Iron Disorders Institute on heart diseases and some of the prevention measures (Iron Disorders Institute, 2020).
Reflection
I had a good time with Mrs Jay throughout the session. Everything went on smoothly even though I lacked the pulse oximeter equipment for assessing her oxygen saturation. She was also very eager to know why I was doing this assessment on her. Other than being part of a class assignment, I explained to her the importance of it in her life. I had a little challenge of language, as Mrs Jay majorly speaks in French, with a bit of English. Thus, I had to translate everything into a language that she could understand better. However, the concept of medication was a bit harder for me since I have not yet done my Pharmacology course. I applied some critical thinking and some online research on this issue. The physical assessment taught me a lot regarding this course.