NURS 3025 Week 10 Head-to-Toe Write-Up Example

Course	NURS 3025 Health Assessment
Week	Week 10
Paper type	Head-to-toe history and physical
Length	About 1,010 words, 6 pages
Format	APA 7 student paper
School	Walden University
Program	Bachelor of Science in Nursing (BSN)
Updated	October 2026

Free sample paper for NURS 3025 Week 10

Head-to-Toe History and Physical: A 55-Year-Old Woman at Her Annual Wellness Visit

Student Name

College of Nursing, Walden University

NURS 3025: Health Assessment

Instructor Name

Month Day, Year

What this page is doingThe title names one person and one visit. A head-to-toe record is long enough that consistency across sections is what gets tested, so everything below uses the same terms throughout.

Head-to-Toe History and Physical: A 55-Year-Old Woman at Her Annual Wellness Visit

History

Identifying data and source: composite 55-year-old woman, a high school librarian, here for her annual wellness visit; the patient is the historian and is reliable. Reason for visit: "Just my yearly checkup. My knees have been bothering me a bit."

Present concerns: bilateral knee aching for about 6 months, worse after climbing stairs and after sitting through long meetings, easing after a few minutes of walking; rates it 3 out of 10; no swelling, locking, or giving way reported. Takes acetaminophen on some evenings.

Past history: hypertension for 6 years, on lisinopril; hypothyroidism for 10 years, on levothyroxine. Surgery: cesarean births at 29 and 33. No known drug allergies. Immunizations: influenza last fall; tetanus-diphtheria booster 8 years ago; she has not received the shingles vaccine. Screening: last mammogram 3 years ago; has never had colorectal cancer screening; cervical screening up to date per her report.

Family history: mother, 79, osteoarthritis and hypertension; father died at 70 of colon cancer; brother, 58, type 2 diabetes.

Social history: married; two adult children. Never smoked. Drinks 1 glass of wine 2 or 3 evenings a week. Walks 20 minutes most lunchtimes. Sleeps 7 hours. Reports her job is "busy but manageable."

Review of systems, by region: General, reports stable weight, no fatigue beyond usual. Skin, no new moles or lesions noticed. Head and eyes, wears reading glasses, no vision change. Ears, nose, throat, no hearing change, no sinus symptoms. Breasts, no lumps or discharge noticed. Respiratory, no cough or breathlessness. Cardiovascular, no chest pain, palpitations, or ankle swelling. Gastrointestinal, bowel movements daily, no bleeding or change in pattern. Genitourinary, menstrual periods stopped 3 years ago; no postmenopausal bleeding; occasional leaking with coughing. Musculoskeletal, knee aching as above. Neurological, no numbness, weakness, or headaches. Psychiatric, no low mood; PHQ-2 score 0. Endocrine, no heat or cold intolerance.

What this page is doingThe history is written in standard order and the review of systems runs region by region to the end, so the physical examination can be read against it section for section.

Physical Examination

General survey: woman who looks her stated age, alert, relaxed, walking in without aid, answering in full sentences. Vital signs: blood pressure 134/82 mm Hg, seated, right arm, after 5 minutes' rest, and 132/80 on repeat; heart rate 72, regular; respiratory rate 14, counted for a full minute; oral temperature 97.9 degrees Fahrenheit; room-air saturation 98%. Height 163 cm; weight 76 kg; body mass index 28.6 kg/m2, calculated.

Skin: even tone; warm and dry; three flat brown macules under 5 mm on the upper back, uniform in color with smooth borders; no other lesions. Hair and nails without abnormality.

Head and face: head normocephalic; no tenderness; face symmetric. Eyes: both pupils the same size and constricting briskly to light; eye movements complete in all directions; conjunctivae pink; fundi not examined because the room could not be darkened, which is stated so it is not read as normal.

Ears: canals clear; both tympanic membranes gray with visible landmarks; whispered words repeated correctly on both sides. Nose and mouth: septum midline; gums and inner cheeks pink and moist, no sores; teeth intact with several fillings; throat clear.

Neck: windpipe central; thyroid of normal size and smooth to touch, without a palpable lump; no cervical or supraclavicular lymph nodes felt.

Breasts: symmetric; no skin changes; no masses on palpation of either breast in all quadrants and the axillary tail; no nipple discharge; no axillary nodes.

Chest and lungs: expansion equal; breath sounds vesicular throughout both lung fields, front and back; no crackles or wheezes (Bickley et al., 2021).

Heart: rhythm regular; first and second heart sounds crisp; no murmur, gallop, or rub; apical impulse not displaced.

Abdomen: soft, flat; bowel sounds present; no tenderness, masses, or enlarged liver or spleen.

Peripheral vascular: radial, femoral, popliteal, and pedal pulses 2+ and symmetric; no ankle swelling; no varicose veins.

Musculoskeletal: knees without swelling, redness, or warmth; fine crepitus felt over both kneecaps with flexion and extension; full range of motion with discomfort at the end of flexion on both sides; no joint line tenderness; no instability. Other joints with full, painless motion.

Neurological: oriented; speech clear; cranial nerves grossly intact; strength 5/5 in all limbs; light touch intact in hands and feet; reflexes 2+ and symmetric; gait steady, able to walk heel to toe.

Genitourinary and pelvic: deferred at the patient's request, as her cervical screening is current; stated here so the record is complete.

Function, Safety, and Wellness Screening

Functional status: independent in all daily activities, including shopping, cooking, and managing her own medications, which she keeps in a weekly organizer. Falls: no falls in the past year; reports no unsteadiness. Home safety: lives in a two-story house; stair rail on one side only; working smoke detectors; wears a seat belt. Vision and hearing: reports no difficulty reading with glasses or following conversation in groups. Mood: PHQ-2 score 0, as recorded in the review of systems. Advance care planning: has not completed an advance directive; asked for information to discuss with her husband. Stress incontinence: reports leaking a small amount with coughing or sneezing about once a week, not limiting activity. Each item is recorded in the same words used in the history above, so the summary that follows can refer back to them without translation.

Summary and Preventive Care

Adult woman with hypertension, near goal on today's readings; hypothyroidism on treatment; bilateral knee aching with crepitus and end-of-range discomfort but no swelling or instability; mild stress urinary incontinence by history; body mass index 28.6.

Preventive care due, based on her age and history: colorectal cancer screening, which the Task Force recommends from age 45 through 75, all the more relevant given her father's colon cancer (US Preventive Services Task Force, 2021); a mammogram, since biennial screening is recommended for women aged 40 to 74 and her last was 3 years ago (US Preventive Services Task Force, 2024); and the shingles vaccine. Findings and due screenings are reported to the provider for the visit plan.

Items for the provider's attention beyond screening: the knee findings, which have not been evaluated before; the stress incontinence, which she had not mentioned at earlier visits; and her request for advance directive information.

What this page is doingTerminology is the same in the history, the examination and the summary: knee aching, crepitus and range are described in the same words each time. Deferred and incomplete parts are named, so their absence is not mistaken for a normal finding.

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.

US Preventive Services Task Force. (2021). Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA, 325(19), 1965-1977. https://doi.org/10.1001/jama.2021.6238

US Preventive Services Task Force. (2024). Screening for breast cancer: US Preventive Services Task Force recommendation statement. JAMA, 331(22), 1918-1930. https://doi.org/10.1001/jama.2024.5534

What the NURS 3025 Week 10 instructions ask for

NURS 3025 Week 10 brings everything together in one full history and physical. You document the full history, examine every system with standard terms, include function and wellness screening and summarize findings with preventive care due. Faculty spread points across completeness, organization, terminology and integration, and length multiplies small errors. Cite the course text and screening guidance in APA 7. Earlier weekly write-ups can be combined if they are updated and made consistent. Unremarkable findings should be written out. The patient should be composite. NURS 3025 faculty want each system examined and written out, function and safety screening included, and a summary that connects findings to preventive care. Note her own health goals for the year.

How the NURS 3025 Week 10 example is put together

Nine to ten pages. The subjective half reproduces the health history format from earlier in the quarter, full review of systems included, for a composite adult at a routine visit with no acute complaint. The objective half opens with a general survey and a vital signs block, then moves through skin, head and neck, eyes, ears, nose and throat, lungs, heart and peripheral vascular, breasts where the prompt includes them, abdomen, musculoskeletal and neurological findings in that sequence. Every system carries its pertinent negatives. Terms and scales introduced in earlier weeks reappear unchanged, so a reflex grade or a pulse strength reads the same way here as it did in its own week. The document closes on a summary of significant findings and a short list of nursing concerns drawn only from the data above.

Where the marks sit in the NURS 3025 Week 10 rubric

Head-to-toe rubrics tend to spread their points across completeness, organization, terminology and integration, and the length of the document multiplies each kind of loss. Completeness is checked system by system, so a missing region, often the peripheral vascular exam or the skin of the lower extremities, costs a full line. Organization is read in the sequence, and a system placed out of order suggests an exam performed out of order. Terminology drift is the costliest pattern here, since a grader who notices inconsistent scales on page eight tends to reread the earlier pages looking for more. Integration frequently carries separate points, earned when reported symptoms and examined findings answer each other. Summaries restating every normal finding and concerns disconnected from data are the usual losses at the close.

Common NURS 3025 Week 10 mistakes, and how to avoid them

Head-to-toe write-ups lose points across a long document through small repeated errors, such as "normal" in place of findings. Write each finding. Another common gap is a summary that lists findings without connecting them to preventive care. Name what is due. Writers also paste earlier write-ups without making them consistent. Check the patient's age and history match throughout. Avoid skipping systems the patient did not complain about. Include function and safety screening. Use current screening intervals. Close with the plan for her knees and the preventive care. Writers also forget to describe the knee examination in detail, though it is her main concern. Record range of motion, swelling and gait. Another frequent slip is outdated screening intervals. Check them.

Get a NURS 3025 Week 10 example written to your instructions

Send the Week 10 prompt and rubric along with your section's head-to-toe template or required system list, and the full record returns on a composite patient in that order, history and physical integrated. Scales match whatever your course set earlier in the quarter. There is no fee for the first sample, and it arrives in 24-48 hours.

More NURS 3025 papers and BSN samples

NURS 3025 Week 10 questions, answered

Can earlier weekly write-ups be combined into this one?

Not directly, and the example shows why. The earlier write-ups each documented a different composite patient, and a head-to-toe record is one person examined in one encounter, so stitched sections contradict each other on age, history and vital signs. The example reuses the earlier weeks' vocabulary and scales while documenting a new patient throughout, which is what graders check for in the integration line.

Are unremarkable findings written out across every system?

Yes, in the body of the record, and they account for most of its length. Each system states what was examined and what was found, so an unremarkable result appears as an actual observation. The summary at the end is where selection happens: it lists only abnormal and visit-relevant findings, which keeps the closing page useful to the next reader instead of repeating ten pages in one.

Is the example's patient real?

No one sat for this exam. The wellness-visit adult is a composite drawn up for the sample, and the ten pages of findings describe a patient who does not exist. If your course pairs this week with a practice partner or a simulated patient, those findings are yours to record, and the sample stays a reference for the finished shape.

Where can I find a free NURS 3025 Week 10 sample paper?

The annual wellness head-to-toe is reproduced here with the full history, every system examined, function and screening, and the summary with preventive care.

What brings the patient in for NURS 3025 Week 10?

An annual wellness visit, plus knees that have been bothering her a bit.