Physical Exam Paper
Running head: PHYSICAL EXAMINATION (PE) WRITTEN DOCUMENTATION
Nursing 200: Complete Physical Examination (PE) Written Documentation Indiana State University
College of Nursing, Health, and Human Services
Nursing 200: Complete Physical Examination (PE) Written Documentation
The format for this paper is based on : Jarvis (2008).
Examiner: , SN ISU Date: 4/12/09
Patient: S.C. Age: 20 Occupation: Full-time nursing student taking 14 hours Language spoken: English
Gender: Marital Status Race: Caucasian
Ethnic affiliation / association: American
Measurements (2 points): • Weight (in lbs & kgs) 125 lbs 56.8kgs • Height (in in & cm) 60 inches 15.2 cm • Waist-to-hip ratio .82 • BMI 21.2 Category normal
Vital signs (2 points): • Radial pulse rate 61 /min; Rhythm regular-regular • Respiratory rate 16 /min; Ease of respirations: easy • Temperature (if indicated) 98.2 degrees ; Route • Blood pressure Right arm 120 / 80 mmHg; Pt position: Left arm 120 / 82 mmHg; Pt position:
General Survey/Mental Status (2 points): well-nourished, well- hydrated; erect, relaxed posture; voluntary, coordinated movements; appears stated age, dress appropriate for age and gender; well-groomed; A/O x3; relaxed expressions, speech clear, articulate, word choice clear, understandable; affect matches stated mood; attentive; college level reading and writing, logical judgment, thought process consistent and realistic; denies suicidal ideation.
Skin, Hair, & Nails (3 points): Skin pinkish tan, light pigmentation, warm and dry; texture smooth and firm, uniform, mobile, immediate recoil when pinched; no vascularity, bruising, lesions;
Hair brown; texture thick, curly; evenly distributed, fully covers scalp; clean with no lesions,bruising.
Nails clean, edges smooth and rounded; uniform thickness, smooth, regular, no clubbing, no sponginess; even distribution; nail pink, capillary refill less than 3
Nursing 200: Complete Physical Examination (PE) Written Documentation Indiana State University
College of Nursing, Health, and Human Services
Nursing 200: Complete Physical Examination (PE) Written Documentation
The format for this paper is based on : Jarvis (2008).
Examiner: , SN ISU Date: 4/12/09
Patient: S.C. Age: 20 Occupation: Full-time nursing student taking 14 hours Language spoken: English
Gender: Marital Status Race: Caucasian
Ethnic affiliation / association: American
Measurements (2 points): • Weight (in lbs & kgs) 125 lbs 56.8kgs • Height (in in & cm) 60 inches 15.2 cm • Waist-to-hip ratio .82 • BMI 21.2 Category normal
Vital signs (2 points): • Radial pulse rate 61 /min; Rhythm regular-regular • Respiratory rate 16 /min; Ease of respirations: easy • Temperature (if indicated) 98.2 degrees ; Route • Blood pressure Right arm 120 / 80 mmHg; Pt position: Left arm 120 / 82 mmHg; Pt position:
General Survey/Mental Status (2 points): well-nourished, well- hydrated; erect, relaxed posture; voluntary, coordinated movements; appears stated age, dress appropriate for age and gender; well-groomed; A/O x3; relaxed expressions, speech clear, articulate, word choice clear, understandable; affect matches stated mood; attentive; college level reading and writing, logical judgment, thought process consistent and realistic; denies suicidal ideation.
Skin, Hair, & Nails (3 points): Skin pinkish tan, light pigmentation, warm and dry; texture smooth and firm, uniform, mobile, immediate recoil when pinched; no vascularity, bruising, lesions;
Hair brown; texture thick, curly; evenly distributed, fully covers scalp; clean with no lesions,bruising.
Nails clean, edges smooth and rounded; uniform thickness, smooth, regular, no clubbing, no sponginess; even distribution; nail pink, capillary refill less than 3
References: in body; Reference pages in | 2 | | |correct format | | | |Organization: brief charting of the PE; Easy to read * |2 | | |Total points: (Upload this sheet with your paper. If the paper is late [for any| | | |reason] 1 point/day will be deducted from the grade.) |50 | | *= do not include breast, anus, or genitalia exam; # = if nodes found, should indicate location, size, shape, tenderness, & mobility Fall 2008