| Course | NR 305 Health Assessment for the Practicing RN |
|---|---|
| Week | 5 |
| Paper type | Head-to-toe examination write-up |
| Length | About 1,220 words, 6 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | RN-to-BSN |
| Updated | October 2026 |
Free sample paper for NR 305 Week 5
Head-to-Toe Examination of a 52-Year-Old Postal Carrier: A Systematic Write-Up
Student Name
College of Nursing, Chamberlain University
NR 305: Health Assessment for the Practicing RN
Instructor Name
Month Day, Year
Head-to-Toe Examination of a 52-Year-Old Postal Carrier: A Systematic Write-Up
Setting and Conditions
Ms. K., a 52-year-old woman who walks a mail route five days a week, volunteered for this examination. It was performed in a skills laboratory with an examination table, adequate overhead light and a room temperature of about 72 degrees Fahrenheit, on a weekday at 1500, about three hours after her lunch. She wore a gown and was draped for each region. The sequence follows the course template, and each entry states the technique used before the finding, so that a reader can judge how the finding was obtained (Jarvis & Eckhardt, 2024). Findings are written as observed, palpated, percussed or heard, without judgments of normal or abnormal; interpretation is limited to the final section.
General Survey and Vital Signs
General survey (inspection): Seated upright, breathing without effort, speaking in full sentences. Dressed in gown, hair combed, nails trimmed. Makes eye contact and answers questions promptly. Gait on entering: steady, even steps, arms swinging symmetrically.
Height and weight (stadiometer, calibrated scale): 165 centimeters; 71.2 kilograms; body mass index calculated at 26.2.
Temperature (oral electronic): 36.8 degrees Celsius.
Pulse (radial, counted 60 seconds): 72 beats per minute, regular.
Respirations (counted 60 seconds while palpating the pulse): 14 per minute.
Blood pressure (automated cuff, adult size, right arm at heart level, after 5 minutes seated, two readings 1 minute apart): 138/86 and 136/88 millimeters of mercury.
Oxygen saturation (finger probe, room air): 98 percent.
Pain (0 to 10 numeric scale): Reports 0.
Skin, Hair and Nails
Inspection and palpation: Skin color even across the trunk; tan on the forearms, back of the neck and the front of the lower legs, with a sharp line at the sock level. Skin warm and dry to the back of the hand. Turgor on the clavicle: returns immediately. A 4-millimeter flat, round, evenly brown lesion with a smooth border on the upper back, left of the spine; Ms. K. reports it has been there for years without change. No other lesions found on full skin inspection.
Hair: Evenly distributed on the scalp; no areas of loss; scalp without flaking.
Nails: Pink nail beds; capillary refill under 2 seconds on the right index finger and right great toe; no clubbing, the angle of the nail base about 160 degrees.
Head, Eyes, Ears, Nose, Mouth and Neck
Head (inspection, palpation): Symmetric; no tenderness or masses over the scalp.
Eyes: Visual acuity (Snellen at 20 feet, with glasses) 20/20 each eye. Lids close fully. Conjunctivae pink; sclerae white. Pupils 3 millimeters, round, constrict briskly to light directly and consensually, and constrict with accommodation. Following a pen through the six cardinal gazes, both eyes move together fully, with no jerking at the extremes. Red reflex present both eyes; the fundus was not visualized clearly because the pupils constricted.
Ears (inspection, otoscope): Canals clear of cerumen; tympanic membranes pearl gray with visible light reflex both sides. Whispered-word test: repeats three of three words each side.
Nose (inspection with light): Septum midline; mucosa pink; no drainage.
Mouth and throat (inspection with light and tongue blade): Lips moist; 26 teeth, two crowns on lower molars; gums pink without bleeding; tongue midline on protrusion; uvula rises midline on saying ah; tonsils not visible behind the pillars.
Neck (inspection, palpation): Trachea midline. Thyroid palpated from behind: not enlarged, no nodules felt, moves up with swallowing. Cervical, preauricular, occipital and supraclavicular nodes: none palpable.
Chest, Lungs and Heart
Thorax (inspection, palpation): Front-to-back depth roughly half the side-to-side width. Chest expands symmetrically about 5 centimeters at the tenth rib. Tactile fremitus equal on both sides.
Lungs (percussion, auscultation with diaphragm, posterior then anterior, side to side): Resonant throughout; diaphragm descends about 5 centimeters on each side with deep breath. Vesicular breath sounds over the lung fields; bronchovesicular sounds near the sternum; no crackles, wheezes or rubs heard.
Heart (inspection, palpation, auscultation with diaphragm and bell in five areas, seated and left lateral): No visible pulsations. Point of maximal impulse felt in the fifth left interspace, in line with the middle of the clavicle, about 1 centimeter across. S1 and S2 heard in all areas, S1 louder at the apex and S2 louder at the base; no extra sounds or murmurs heard with diaphragm or bell. Rate and rhythm match the radial pulse.
Breasts (inspection seated with arms at sides, raised and pressed on hips; palpation supine with vertical strip pattern): Symmetric; no dimpling or nipple retraction; tissue without discrete masses; no nipple discharge; axillary nodes not palpable. Ms. K. reports her last mammogram 14 months ago.
Abdomen
Inspection (supine, knees slightly flexed): Flat; healed 3-centimeter scar at the umbilicus, which Ms. K. attributes to laparoscopic gallbladder removal 9 years ago.
Auscultation (before palpation, diaphragm, four quadrants): Bowel sounds heard in all four quadrants, about 8 per minute; no bruit heard over the aorta, either renal artery or the iliac arteries.
Percussion: Tympanic note over most of the abdomen; liver dullness spans 8 centimeters at the right midclavicular line.
Palpation (light then deep): No tenderness, masses or guarding; liver edge not felt below the costal margin; spleen not felt; no costovertebral angle tenderness on fist percussion.
Musculoskeletal, Neurologic and Peripheral Vascular
Musculoskeletal (inspection, palpation, range of motion, strength testing against resistance): Full active range of motion in all major joints without pain. Strength 5 of 5 in upper and lower extremities bilaterally. Mild bony enlargement at the distal joints of the second and third fingers of both hands, not tender; Ms. K. reports morning stiffness in the fingers for under 15 minutes. Spine straight on forward bending.
Neurologic: Oriented to person, place, date and purpose. Cranial nerves II through XII tested and intact. Light touch and sharp-dull discrimination intact on hands and feet. Monofilament felt at all ten sites on both feet. Deep tendon reflexes 2+ at biceps, triceps, brachioradialis, patellar and Achilles, symmetric. Romberg: steady with eyes closed. Coordination: she touches finger to nose and runs each heel down the opposite shin smoothly and on target.
Peripheral vascular (palpation, inspection): At the radial, femoral and popliteal sites and at both foot sites, the top of the foot and behind the inner ankle, each pulse is graded 2+, with right matching left. No edema at ankles or shins. Calluses over the heads of the first metatarsals on both soles; no open areas between the toes.
Summary of Findings Outside Expected Values
Most findings fall within expected values for an adult of Ms. K.'s age (Ball et al., 2023; Bickley et al., 2021). Four findings are noted for follow-up rather than interpreted. First, two blood pressure readings in the elevated range, which would need to be confirmed on separate occasions before any conclusion is drawn. Second, a body mass index of 26.2. Third, bony enlargement of the distal finger joints with brief morning stiffness. Fourth, a long-standing pigmented lesion on the back that Ms. K. reports has not changed; she was advised to have it recorded at her next skin check. Ms. K. was told of each finding in plain terms and advised to share the blood pressure readings with her primary care clinician.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.
The Chamberlain NR 305 Week 5 instructions
Week 5 has each RN-to-BSN student examine one volunteer from head to toe, recording every system in the template's sequence. Expect every system from general survey and vital signs to neurologic and peripheral vascular, with technique named before each finding. Record the conditions of the examination, such as light, room temperature and time since eating. Write normal findings out instead of using within normal limits. Give measurements with units and distinguish right from left. Describe any lesion by size, shape, color and border without naming it. Note any part your volunteer declined. End with a summary of findings outside expected values and their follow-up.
Inside the NR 305 Week 5 example
The write-up opens with Ms. K., her five-day walking route, the lab setting and the rule of technique before finding. The general survey and vital signs list each measurement with its method, including two blood pressure readings a minute apart. Skin, hair and nails follow, with a lesion described rather than labeled. Head, eyes, ears, nose, mouth and neck are recorded with Snellen results and node checks. Chest, lungs, heart and breasts follow, then the abdomen with listening before pressing. Musculoskeletal, neurologic and peripheral vascular sections close the examination. A summary lists four findings for follow-up, citing Ball et al. (2023) and Bickley et al. (2021). Each finding sits under the technique that produced it.
Where the points sit in the NR 305 Week 5 rubric
Head-to-toe rubrics typically grade completeness in template order, correct technique, precise description of normal and abnormal findings, measurements with units, bilateral comparison and an appropriate summary. Precision carries heavy weight, so normal findings are written out instead of summarized. Technique scores when it is named before each finding. Completeness is graded against the template order, which the paper follows exactly. Measurements earn credit with units and methods, such as blood pressure after five minutes seated. The summary is credited when it lists findings outside expected values with follow-up and no diagnosis. Recording the conditions of the examination shows awareness of what can change a finding. Clear left and right labels finish the comparison row.
NR 305 Week 5 help: mistakes that cost points
The predictable loss is within normal limits applied system after system, which tells a grader nothing. Interpretation mixed into findings, such as calling a system healthy, costs points next. Techniques never named, measurements without units, left and right blurred, terms drifting between systems, systems omitted without a note and sections out of template order all lose marks. None require more skill, only patience. Within normal limits may appear in a summary, not in place of findings. If your volunteer declines part of the examination, record that and why. This write-up is more detailed than charting at work. Share your notes, and a write-up can be organized in template order.
Get a NR 305 Week 5 example written to your instructions
Send the Week 5 instructions and the assessment template your section issues, and a custom example is written into your own format and returned inside 24 to 48 hours. The first one is free. The examination and any consent your participant gives are yours to arrange and record.
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NR 305 Week 5 questions, answered
Can I write within normal limits at all?
Sparingly, and only where your section permits it. Rubrics on this assignment usually reward described normals, because the description is the evidence that the system was examined. A safe approach is to write findings out and reserve any summary phrase for a closing statement rather than using it as the entry for a system.
What if my volunteer will not consent to part of the exam?
Record the omission and the reason in general terms, and carry on. Assessment courses expect boundaries with volunteer participants, and a document that notes them reads as honest rather than incomplete. Inventing findings for a region that was not examined is the one thing here that turns a low grade into a bigger problem.
How is this different from what I chart at work?
Charting is compressed for colleagues who share your context; this is written for a reader who was not there and is checking that each step happened. That is why techniques get named and normals get described. The skill is the same and the record is longer, which is the adjustment most working nurses have to make in this course.
Where can I find a free NR 305 Week 5 sample paper?
The full Week 5 head-to-toe write-up on Ms. K., with every system in template order and the four findings listed for follow-up, is published on this page.
Why doesn't the NR 305 Week 5 example say within normal limits?
Writing normal findings out lets a later examiner compare them precisely; the summary notes which findings fall within expected values and which, such as two elevated blood pressures, need follow-up.