DOCUMENTATION of Physical findings

Part 1: Documentation of Normal findings
Using proper documentation and medical terminology, provide a sample documentation of a heart and vascular assessment of a person with no abnormal findings. Utilize the format:
Vital Signs:
Neck Vessels
• Inspection:
• Palpation:
• Auscultation:
Precordium
• Inspection:
• Palpation:
• Auscultation:
Extremities
• Inspection:
• Palpation:
Part 2: Documentation of Abnormal findings
Using proper documentation and medical terminology, provide a sample documentation of the heart and vascular assessment of a person with Heart failure. Utilize the format:
Vital Signs:
Neck Vessels
• Inspection:
• Palpation:
• Auscultation:
Precordium
• Inspection:
• Palpation:
• Auscultation:
Extremities
• Inspection:
• Palpation:
Next, explain the pathophysiology behind each abnormal finding documented above for the patient with heart failure. In other words, what physical changes have occurred in the body to produce the abnormal findings? Please list each abnormal finding along with the pathophysiology explanation.

 

 

 

Sample Solution

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