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

Student Name

Capella University

NURS-FPX4015

Professor Name

Submission Date

Marco Mancini – Physical Assessment Transcript

Nurse: Well, good morning, Mr. Mancini. My name is Shazia. Today I will be doing your head to toe physical examination. I know you have been experiencing certain sleeping problems and anxiety. Would it be alright to go ahead with the assessment before we start?

Client: Yes, that’s fine.

Nurse (professional demeanor): You are welcome. During the exam, be able to inform me that you are not comfortable or have to rest. We shall start with measuring 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 known hypertension diagnosis.

General Appearance

Mr. Mancini is of the correct age, dressed and groomed well. He maintains good eye contact and appears slightly nervous. His speech is clear though there are times that he stops speaking when talking on emotionally sensitive issues.

Nurse: I can notice that you are tense. You are feeling good–you are very open.

Neurological & Cognitive Status

Level of Consciousness: Alert and oriented ×4 (person, place, time, situation)
Cognition: Mild impairment in concentration in responding to emotionally evoking 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: Are you able to count backwards by sevens starting with 100?

Client: 93… 86… 79… umm… 72…

Note: Processing slowed, however, proper effort and accuracy were observed.

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

Head: Normocephalic, atraumatic
Eyes: PERRLA, no nystagmus
Ears: Tympanic membranes clear bilaterally
Nose: Mucosa pink, no congestion
Mouth/Throat: Moist mucous membranes, no lesions, teeth intact.

Skin

Color: Normal for ethnicity
Temperature: Warm, dry
Turgor: Good elasticity
Lesions: No rashes, ulcers, or abnormal findings
Psychomotor activity: No apparent self-harm, scarring.

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

Mood: “Some days I feel guilty… I get scared easily.”
Affect: Constricted but appropriate
Thought processes: Logical and goal-directed
Insight/Judgment: Fair
Suicidal ideation: Denies current or past SI/HI
Sleep: Problems in sleeping because of nightmares and flashbacks.
Coping mechanisms: Avoidance (e.g., violence in media), isolation

Nurse: I am glad you told me, Marco. Understanding how these memories affect your everyday life is important. You are not the only one and we are to assist in your recovery process.

Plan of Care – Immediate Follow-Up

Continue lisinopril for hypertension
Citalopram 20 mg for depression/anxiety
Prazosin 1 mg qHS for nightmares
Closing Statement
Assess for orthostatic hypotension related to medication interactions
Refer for individual psychotherapy (CBT)
Educate the patient about PTSD, medication side effects, and suicide prevention resources.
Arrange follow-up with Psychiatric NP in three weeks

Nurse: Thank you again, Marco. Today you are open, and this will assist us in constructing a robust care plan. You are improving, and you will not stop collaborating with us in order to achieve your recovery. Please do not hesitate to reach out to us if any concerns arise before your next scheduled visit. We will follow up with you in a week and three weeks to have a therapy session and medication follow-up, respectively.