| Course | NR 509 Advanced Physical Assessment |
|---|---|
| Week | 2 |
| Paper type | Physical exam documentation |
| Length | About 1,180 words, 3 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, nurse practitioner core |
| Updated | October 2026 |
Free sample paper for NR 509 Week 2
Documentation Assignment: A Normal Adult Examination of a 29-Year-Old Warehouse Worker Written as Observations, With Position, Side and Measurement Recorded and the Systems Not Examined Named
Student Name
College of Nursing, Chamberlain University
NR 509: Advanced Physical Assessment
Instructor Name
Month Day, Year
Documentation Assignment: A Normal Adult Examination of a 29-Year-Old Warehouse Worker Written as Observations, With Position, Side and Measurement Recorded and the Systems Not Examined Named
Context
Mr. T. N., 29, a warehouse order picker, presented for a pre-employment physical examination required by a new employer. He reports no current symptoms and no chronic conditions, takes no medications and has no allergies. The examination below follows the course template in order. Every normal finding is written as an observation, with position, side and measurement where they apply, because "within normal limits" does not show what was examined (Bickley et al., 2021). Systems not examined are listed at the end with the reason.
General Survey and Vital Signs
General survey: Awake and attentive; knew who and where he was, the date and why he had come. Well groomed, dressed appropriately for the weather. Walked into the room with a steady, symmetric gait and sat without assistance. Speech clear and fluent. Makes eye contact; affect appropriate to conversation. No apparent distress.
Vital signs: Blood pressure 118/76 mm Hg, right arm, seated with back supported and feet flat for 5 minutes, appropriately sized adult cuff; repeat 116/74 mm Hg after 1 minute, following the recommended technique of averaging two readings (Muntner et al., 2019). Heart rate 68 beats per minute, regular, radial pulse counted for 30 seconds and doubled. Respiratory rate 14 breaths per minute, unlabored, counted without the patient's awareness. Temperature 36.8°C oral. Oxygen saturation 99% on room air, right index finger. Height 178 cm, weight 79 kg, body mass index 24.9 kg/m2.
Skin, Hair and Nails
Skin warm, dry and uniformly light brown on inspection of face, trunk and all four extremities; no rashes, lesions or bruising. Turgor brisk over the clavicle; returned immediately. Two flat, evenly pigmented brown macules on the upper back, each about 3 mm, with regular borders. Scalp hair full and even, with no patchy loss. Nail beds pink, blanching and refilling within 2 seconds when each finger was pressed; no clubbing, pitting or splinter hemorrhages.
Head, Eyes, Ears, Nose and Throat
Head: Skull of normal size and shape; no masses or tenderness on palpation of the scalp. Eyes: Read the 20/20 line of a Snellen chart at 20 feet with the right eye covered and again with the left, without glasses. Conjunctivae pink, sclerae white. Pupils equal, round, 3 mm, narrowing to 2 mm when light was shone in that eye and when it was shone in the other, tested both sides. Extraocular movements full in six directions with no nystagmus. Red reflex present both sides; optic disc margins crisp in both eyes, the central cup occupying roughly a third of each disc. Ears: Auricles without lesions; canals clear; eardrums translucent gray, each with a cone of reflected light at the expected position. Whispered words repeated correctly at arm's length, each ear. Nose: Septum midline; mucosa pink; no discharge. Mouth and throat: Lips and buccal mucosa moist and pink. Teeth in good repair. Tongue midline on protrusion. Uvula rises symmetrically with phonation. Tonsils not enlarged, grade 1.
Neck and Lymph Nodes
Trachea midline on palpation. Thyroid not visible on swallowing; on palpation from behind, isthmus felt, lobes smooth, not enlarged, no nodules, moves with swallowing. No lymph nodes palpable in the preauricular, posterior auricular, occipital, submandibular, submental, anterior and posterior cervical, or supraclavicular chains, both sides. Full range of neck motion without pain.
Chest, Lungs and Heart
Chest and lungs: Chest symmetric; anteroposterior diameter less than lateral. Expansion symmetric on palpation at the tenth ribs posteriorly. Tactile fremitus equal both sides. Resonant to percussion throughout all lung fields, anterior and posterior. With him seated and breathing deeply through an open mouth, soft, low-pitched breath sounds were heard in every field, with no crackles, wheezes or rubs.
Cardiovascular: Apical impulse palpable just inside the left midclavicular line at the fifth rib space, roughly the size of a fingertip; no lift of the sternum and no palpable vibration. Rhythm regular at a normal rate. First and second heart sounds heard clearly at the aortic, pulmonic, tricuspid and mitral areas with the diaphragm and bell; the second sound split into two components during inspiration at the left upper sternal border and merged again on expiration, a normal pattern. No S3, S4, murmurs or rubs, including with the patient in the left lateral position. Jugular venous pressure not elevated with the torso raised to about 45 degrees. Carotid upstrokes brisk, 2+ both sides, no bruits. Pulses graded 2+ and matched side to side at the wrists, groins, tops of the feet and behind the medial malleoli. No edema of the ankles or shins.
Abdomen
Supine with knees slightly flexed. Abdomen flat and symmetric; umbilicus midline without hernia. Bowel sounds present in all four quadrants, listened to for about 15 seconds each. Tympanic to percussion over most of the abdomen. Liver dullness spanned 8 cm in the right midclavicular line; the lower edge could not be felt beneath the ribs on deep inspiration. No splenic tip felt; Traube's space tympanic. Soft on both shallow and deep palpation of every quadrant, with no tenderness, guarding or mass. No costovertebral angle tenderness, both sides.
Musculoskeletal and Neurologic
Musculoskeletal: Viewed from behind while standing, the spine showed no lateral curve; no tenderness over the spinous processes. Full active range of motion of the shoulders, elbows, wrists, hips, knees and ankles, both sides, without pain or crepitus. No joint swelling or deformity. Forward bend to touch toes without pain; lifting squat performed smoothly, relevant to his job.
Neurologic: Cranial nerves II through XII grossly intact: visual fields full to confrontation, facial movements symmetric, hearing as above, palate rises, tongue midline, shoulder shrug strong both sides. Full 5/5 strength, right equal to left, when resisting the examiner at the shoulders, elbows, hands, hips, knees and ankles. Identified a wisp of cotton touched to each hand and each foot with his eyes closed. Tendon reflexes 2+ and symmetric at biceps, triceps, brachioradialis, patellar and Achilles tendons; plantar responses flexor both sides. Touched his nose and the examiner's finger smoothly and ran each heel down the opposite shin without wavering. Romberg negative. Tandem gait steady.
Mental Status
Calls his mood "good," and his expression matches it. Answers follow logically from the questions asked. Denies thoughts of harming himself or others. Recalled three words at 5 minutes.
What Was Not Assessed
Genitourinary, hernia and rectal examinations were not performed; they are not required for this employer's physical, the patient reports no symptoms in these areas, and he declined when offered. A full sensory examination with monofilament and vibration was not performed because he has no diabetes or neurologic symptoms. Naming these gaps is part of the record: a reader will know they were omitted by decision, not forgotten.
References
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.
Muntner, P., Shimbo, D., Carey, R. M., Charleston, J. B., Gaillard, T., Misra, S., Myers, M. G., Ogedegbe, G., Schwartz, J. E., Townsend, R. R., Urbina, E. M., Viera, A. J., White, W. B., & Wright, J. T., Jr. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. https://doi.org/10.1161/HYP.0000000000000087
NR 509 Week 2 instructions, in plain terms
The Week 2 assignment asks you to document a complete physical examination using correct terminology. Students are usually asked for vital signs, a general survey and every major system in a standard order, written as findings, with APA. Write each normal finding as what you did and what you found, not as "normal" or "unremarkable." Record position, side and measurement, such as how blood pressure was taken. In the abdomen, listen before you press. Use precise terms, such as the location of the apical impulse. Name any system you did not examine and say why, rather than leaving it out. Note the cuff size and arm used.
Inside the NR 509 Week 2 example
The context section describes Mr. T. N., a warehouse order picker, and the pre-employment purpose. The general survey records alertness, orientation, grooming and gait. Vital signs include 118/76 measured on the right arm, seated with back supported and feet flat for five minutes, with a repeat. Skin is described by temperature, moisture and turgor. The eyes include a 20/20 Snellen reading at 20 feet. The neck records the trachea midline and a smooth, nonenlarged thyroid. The chest records symmetric expansion and resonance. The heart records the apical impulse inside the left midclavicular line at the fifth space. The abdomen follows the correct order with knees flexed. The final section explains that genitourinary, hernia and rectal examinations were not done.
Reading the NR 509 Week 2 grading rubric
Documentation rubrics in NR 509 generally score completeness, accurate terminology, logical organization, objective description, appropriate technique and APA. This week turns on objective description, so every normal finding is written as an observation with position and side. Completeness is credited because each system appears and omissions are explained. Terminology scores through precise landmarks and methods. Technique earns points for blood pressure measured as the AHA statement by Muntner and colleagues describes. Organization follows a standard head-to-toe order. Bates' guide supports the methods. Two references complete APA. Naming the systems not examined, with reasons, protects the completeness row. Measuring blood pressure twice shows the technique the rubric expects.
NR 509 Week 2 help: mistakes that cost points
The characteristic Week 2 loss is the blanket normal: a system summarized as unremarkable with nothing to show it was examined. Close behind is an examination with no positions or sides, so a reader cannot tell how findings were obtained. Students also leave out systems without comment, use vague terms such as "clear" without saying where they listened or order techniques incorrectly in the abdomen. When everything is normal, the detail of what you did is what earns the points. Include systems you did not examine with a reason. Clinical vocabulary is expected but should be accurate. Send your examination notes, and an NR 509 documentation can be written finding by finding. Write what you did, not what you concluded.
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NR 509 Week 2 questions, answered
Everything on my patient was normal. What is there to write?
More than it seems. A normal finding is only worth marks when the document shows how it was established, so each system carries what was inspected, palpated or auscultated and what resulted. An all-normal examination written specifically scores well; the same examination written as a list of reassurances does not.
Should I include systems I did not examine?
Name them as not assessed, with a reason. A grader reading a document with a system silently missing cannot tell whether it was skipped or forgotten, and assumes the latter. An honest gap costs far less than an invisible one. Say so under the system's own heading rather than in a closing note, so the gap appears where the finding would have been.
How much clinical vocabulary is expected this early?
Enough that the document reads as a clinical record rather than a description. Findings should be named the way they are named in practice, and positions and maneuvers should be stated. Week 2 is where that register is being established, so it is marked more closely than the content alone would suggest.
Where can I find a free NR 509 Week 2 sample paper?
This page has the complete Week 2 documentation of a normal adult examination, every system written as observations, the systems not assessed and two references.
How is blood pressure documented in the NR 509 Week 2 example?
As 118/76 on the right arm, seated with back supported and feet flat after five minutes' rest, with an appropriately sized adult cuff and a repeat reading.