No visible deformities. Muscles are bilaterally equivalent in strength. No visible deformities. Muscles are bilaterally firm and well-developed. Arm and leg musculature are equal in appearance with no obvious deformities. Fat and muscle distribution are evenly distributed.
Patient is alert and oriented to time, place, self, and situation. Able to respond appropriately to conversation and questions. Patient obeys commands. Patient does not display any obvious signs of pain. Patient affect is responsive and no blunted. Easily expresses emotional and is cooperative with questions.Movements are relaxed and purposeful.
Behavior is appropriate for situation. 10. Observe facial expression (claustrophobia’s eye contact and facial expression).
1 1 . Observe speech (pattern and style). Client smiles with relaxed and appropriate facial expressions. Client maintains eye contact.
Client displays a full Range of Motion with no presence of guarding or tension. Speech is clear and pattern is moderately paced. Vital Signs 98. 9 F 12. Temperature 13. Heart rate (pulse– rhythm, amplitude) 14. Respirations (rate, rhythm, and depth). 15.
Blood pressure 58 16-18 breaths per minute.Inspirations are shallow and unloaded with no adventitious lung sounds. Bilateral chest expansion are symmetrical with each breath. 118/68. Nutritional assessment: Subjective data 1 . Type of diet (for instance, low Carr, vegetarian, diabetic, etc.
) 2. Appetite changes 3. Weight changes in last 6 months? 4.
Problems with indigestion, heartburn, bloating, 5. Constipation or diarrhea? Low Carr diet. Denies appetite changes. Gain of 10 pounds in the past 6 months 6 6.
Dental problems? 7. Conditions/diseases affecting intake or absorption, i. E. , irritable bowel disease, gluten necessities, etc.
? 8. Frequency of dieting? Patient denies dieting. States he does not believe in dieting but does try to restrict the amount of “crabs I eat”. 9.
Chronic diseases? 10. Weight issues? Maternal Grandmother breast cancer. History of adolescent morbid obesity. Lifestyle and Health Practices 11. Average daily food intake-?how many meals and snacks? 12.
Approximately how many 8-oz. Glasses of fluid per day are consumed? 13. Type of beverages 14. Dine alone or with others? 15. Frequency of eating out? 16. DO long work hours affect diet? 17. Sufficient income for food? 8.
List a 24 hour recall of food intake. 3 meals per day. 3-5 snacks per day. Patient reports 10-12 glasses per day.
Reports mainly consumes water and 1-2 cups Of coffee per day.