Running head: FINAL PROJECT ADVANCED PHYSICAL ASSESSMENT 1
Final Project Advanced Physical Assessment
American Sentinel University
Advanced Physical Assessment
N522PE
, FINAL PROJECT ADVANCED PHYSICAL 2
ASSESSMENT
Final Project Advanced Physical Assessment
In the final project for Advanced Physical Assessment, a comprehensive exam was
performed on the patient Tina Jones. I will synthesize and summarize the history, assessments,
and key findings during the exam. Clinical evidence shall be defined to support clinical
reasoning. The findings of the physical assessment shall be prioritized in regards to patient’s
health. An individualized care plan will be produced for the patient based on clinical findings.
One nursing theory will be applied to the patient’s plan of care. Plan of care is individualized to
findings, life-span stage of development with culturally specific considerations, and patient-
centered. Healthy People 2020 objectives will be Incorporate into the plan of care prioritized to
meet the health needs of the patient. Standards of the professional nursing practice will be
explained regarding an assessment of patients.
The patient Tina Jones a 28-year-old female reports to the local clinic status post an
injury to her right foot two weeks ago. Ms. Jones went to the emergency room for medical care
after the injury. She tripped down stairs and sustained a scrap to the bottom of her right foot,
and a twisted ankle. An x-ray was performed, and results were negative for a fracture. The
wound was cleansed and bandaged. A tetanus booster was administered. Pain medication
prescribed; tramadol 50mg po prn. The patient discloses while discussing the pain medication
with the emergency room staff she was not listening and is not sure of the proper frequency as
she states she had no plans to take and was not listening. During the assessment, the patient
blood sugar was deemed high, but no actual number was defined. The patient at that time stated
that she had been diagnosed with diabetes three years ago. She disclosed to the physician at the
emergency room she had not had a checkup in three years. She was instructed to obtain an
appointment.
Final Project Advanced Physical Assessment
American Sentinel University
Advanced Physical Assessment
N522PE
, FINAL PROJECT ADVANCED PHYSICAL 2
ASSESSMENT
Final Project Advanced Physical Assessment
In the final project for Advanced Physical Assessment, a comprehensive exam was
performed on the patient Tina Jones. I will synthesize and summarize the history, assessments,
and key findings during the exam. Clinical evidence shall be defined to support clinical
reasoning. The findings of the physical assessment shall be prioritized in regards to patient’s
health. An individualized care plan will be produced for the patient based on clinical findings.
One nursing theory will be applied to the patient’s plan of care. Plan of care is individualized to
findings, life-span stage of development with culturally specific considerations, and patient-
centered. Healthy People 2020 objectives will be Incorporate into the plan of care prioritized to
meet the health needs of the patient. Standards of the professional nursing practice will be
explained regarding an assessment of patients.
The patient Tina Jones a 28-year-old female reports to the local clinic status post an
injury to her right foot two weeks ago. Ms. Jones went to the emergency room for medical care
after the injury. She tripped down stairs and sustained a scrap to the bottom of her right foot,
and a twisted ankle. An x-ray was performed, and results were negative for a fracture. The
wound was cleansed and bandaged. A tetanus booster was administered. Pain medication
prescribed; tramadol 50mg po prn. The patient discloses while discussing the pain medication
with the emergency room staff she was not listening and is not sure of the proper frequency as
she states she had no plans to take and was not listening. During the assessment, the patient
blood sugar was deemed high, but no actual number was defined. The patient at that time stated
that she had been diagnosed with diabetes three years ago. She disclosed to the physician at the
emergency room she had not had a checkup in three years. She was instructed to obtain an
appointment.
