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NR304 Health Assessment II
RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment_Guidelines_V6_Final 1
Purpose
As you learned in NR302, before any nursing plan of care or intervention can be implemented or evaluated, the
nurse conducts an assessment, collecting subjective and objective data from an individual. The data collected
are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will
focus on collecting both subjective and objective data, synthesizing the data, and identifying health and wellness
priorities for the person. The purpose of the assignment is twofold.
1. To recognize the interrelationships of subjective data (physiological, psychosocial, cultural and spiritual
values, and developmental) and objective data (physical examination findings) in planning and
implementing nursing care.
2. To reflect on the interactive process that takes place between the nurse and an individual while conducting
a health assessment and a physical examination.
Course outcomes: This assignment enables the student to meet the following course outcomes.
CO 1: Explain expected client behaviors while differentiating between normal findings, variations and
abnormalities. (PO1)
CO 2: Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate
clinical judgment in professional decision-making and implementation of nursing process while
obtaining a physical assessment. (POs 4 and 8)
CO 3: Recognize the influence that developmental stages have on physical, psychosocial, cultural, and
spiritual functioning. (PO 1)
CO 4: Utilize effective communication when performing a health assessment. (PO 3)
CO 5: Demonstrate beginning skill in performing a complete physical examination using the techniques of inspection,
palpation, percussion, and auscultation. (PO 2)
CO 6: Identify teaching/learning needs from the health history of an individual. (POs 2 and 5)
CO 7: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing
appropriate documentation. (POs 6 and 7)
Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this
assignment.
Total points possible: 100 points
Preparing the assignment
Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
1. Complete a health history and physical examination on an individual. Using the following subjective and objective
components, as well as your textbook for explicit details about each category, complete a health history and physical
examination on an individual. You may choose to complete portions of this assignment as you obtain the health
history and perform the physical examination associated with the body systems covered in NR304. The person
interviewed must be 18 years of age or older. Please be sure to avoid the use of any identifiers in preparing the
assignment and follow HIPAA protocols.
2.
a. Students may seek input from the course instructor on securing an individual for this assignment.
b. Avoid the use of client identifiers in the assignment, HIPAA protocols must be utilized.
c. During the lab experiences, you will conduct a series of physical exams that include the systems listed in
Objective Data below.
d. Refer to the course textbook for detailed components of each system exam.
1) Remember, assessment of the integumentary system is an integral part of the physical exam and should be
2
NR304 Health Assessment II
RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment_Guidelines_V6_Final 2
included throughout each system.
e. Keep notes on each part of the health history and physical examination as you complete them so that you can
refer to the notes as you write the paper, particularly the reflection section.
f. Utilize proper medical terminology.
3. Include the following sections, used as section headers within the paper.
a. Health History: Subjective Data (30 points/30% [1-2 paragraphs in length])
1) Demographic data
2) Reason for care
3) Present illness (PQRST of current illness)
4) Perception of health
5) Past medical history (including medications, allergies, and vaccinations and immunizations)
6) Family medical history
7) Review of systems
8) Developmental considerations
9) Cultural considerations
10) Psychosocial considerations
11) Presence or absence of collaborative resources (community,
family, groups, and healthcare system)
b. Physical Examination: Objective Data (30 points/30% [1 paragraph])
1) From NR302
a) HEENT (head, eyes, ears, nose, and throat)
b) Neck (including thyroid and lymph chains)
c) Respiratory system
d) Cardiovascular system
2) From NR304
a) Neurological system
b) Gastrointestinal system
c) Musculoskeletal system
d) Peripheral vascular system
c. Needs Assessment (20 points/20% [2 paragraphs])
1) Based on the health history and physical examination findings, determine at least two health education
needs for the individual. Remember, you may identify an educational topic that is focused on wellness.
2) Support the identified health teaching needs selected with evidence from two current, peer-reviewed
journal articles.
3) Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations
will influence, assist, or become barriers to the effectiveness of the proposed health education.
4) Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical,
community, and health and wellness resources) effect proposed teaching.
d. Reflection (10 points/10% [1 paragraph])
Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to
evaluate outcomes. Provide a written reflection that describes your experience with conducting this
complete health history and physical assessment.
1) Reflect on your interaction with the interviewee holistically.
a) Describe the interaction in its entirety: include the environment, your approach to the individual,
time of day, and other features relevant to therapeutic communication and to the interview process.
2) How did your interaction compare to what you have learned?
3) What barriers to communication did you experience?
a) How did you overcome them?
b) What will you do to overcome them in the future?
4) What went well with this assignment?
5) Were there unanticipated challenges during this assignment?
6) Was there information you wished you had available but did not?
3
NR304 Health Assessment II
RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment_Guidelines_V6_Final 3
7) How will you alter your approach next time?
e. Writing Style and Format (10 points/10%)
1) Writing reflects synthesis of information from prior learning applied to completion of the assignment.
2) Grammar and mechanics are free of errors.
3) Able to verbalize thoughts and reasoning clearly.
4) Use appropriate resources and ideas to support topic.
5) Adheres to APA recommendations for title page, running head, headings, in-text citations, and reference
page.
6) HIPAA protocols followed.
For writing assistance (APA, formatting, or grammar), visit the APA Citation and Writing Assistance page in the online
library.
Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned in the review material.
https://library.chamberlain.edu/APA
NR304 Health Assessment II
RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment_Guidelines_V6_Final 4
Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper
Health History: Subjective Data
(30 points/30%)
30 points 28 points 23 points 15.5 points 0 points
Required criteria
1. Demographic data
2. Reason for care (why they are in the facility)
3. Present illness (PQRST of current illness)
4. Perception of health
5. Past medical history (including medications, allergies, and
vaccinations and immunizations)
6. Family medical history
7. Review of systems
8. Developmental considerations
9. Cultural considerations
10. Psychosocial considerations
11. Presence or absence of collaborative resources (community,
family, groups, and healthcare system)
Includes 11
requirements for
section.
Includes 9-10
requirements for
section.
Includes 5-8
requirements
for section.
Includes 1-4
requirements for
section.
No requirements
for this section
presented.
Physical Examination: Objective Data
(30 points/30%) 30 points 28 points 23 points 15.5 points 0 points
Required criteria
1. From NR302
o HEENT (head, eyes, ears, nose, and throat)
o Neck (including thyroid and lymph chains)
o Respiratory system
o Cardiovascular system
2. From NR304
o Neurological system
o Gastrointestinal system
o Musculoskeletal system
o Peripheral vascular system
Includes 8
requirements for
section.
Includes 7
requirements for
section.
Includes 4-6
requirements
for section.
Includes 1-3
requirements for
section.
No requirements
for this section
presented.
Needs Assessment
(20 points/20%)
20 points 18 points 15 points 7.5 points 0 points
Required criteria
1. Based on the health history and physical examination findings,
determine at least two health education needs for the individual.
Includes 4
requirements for
section.
Includes 3
requirements for
section.
Includes 2
requirements
for section.
Includes 1
requirement for
section.
No requirements
for this section
presented.
NR304 Health Assessment II
RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment_Guidelines_V6_Final 5
Remember, you may identify an educational topic that is focused
on wellness.
2. Support the identified health teaching needs selected with
evidence from two current, peer-reviewed journal articles.
3. Discuss how the interrelationships of physiological, developmental,
cultural, and psychosocial considerations will influence, assist, or
become barriers to the effectiveness of the proposed health
education.
4. Describe how the individual’s strengths (personal, family, and
friends) and collaborative resources (clinical, community, and
health and wellness resources) effect proposed teaching.
Reflection
(10 points/10%)
10 points 9 points 8 points 4 points 0 points
Required criteria
1. Describe the interaction in its entirety: include the environment,
your approach to the individual, time of day, and other features
relevant to therapeutic communication and to the interview
process.
2. How did your interaction compare to what you have learned?
3. What went well?
4. What barriers to communication did you experience?
5. How did you overcome them?
6. What will you do to overcome them in the future?
7. Were there unanticipated challenges to the interview?
8. Was there information you wished you had obtained?
9. How will you alter your approach next time?
Includes 9
requirements for
section.
Includes 7-8
requirements for
section.
Includes 5-6
requirements
for section.
Includes 1-4
requirements for
section.
No requirements
for this section
presented.
Style and Organization
(10 points/10%)
10 points 9 points 8 points 4 points 0 points
Required criteria
1. Writing reflects synthesis of information from prior learning
applied to completion of the assignment.
2. Grammar and mechanics are free of errors.
3. Able to verbalize thoughts and reasoning clearly.
4. Use appropriate resources and ideas to support topic.
5. Adheres to APA recommendations for title page, running head,
headings, in-text citations, and reference page.
6. HIPAA protocols followed.
Includes 6
requirements for
section.
Includes 5
requirements for
section.
Includes 4
requirements
for section.
Includes 1-3
requirements for
section.
No requirements
for this section
presented.
Total Points Possible = 100 points
NR304 Health Assessment II
RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment_Guidelines_V6_Final 6
Purpose
Course outcomes: This assignment enables the student to meet the following course outcomes.
- Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.
Total points possible: 100 points
Preparing the assignment
Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.
Chamberlain University College of Nursing
Health Assessment 2
Dr. Christina Johnson
Assignment Due Date:
Well Woman Check-up
Demographic Data
Mrs. R.K.B, a female African American aged 25, visited the hospital at Sugarland for her yearly well-woman visit on September 21st, 2020. A happily married woman who decided to go back to school as a full-time student. She is a mother of two children, a male, and a female.
Past Medical History
She stated, and her medical record shows she had completed her tetanus, hepatitis, chickenpox, and MMR earlier as a child. She had no records of surgeries or any hospitalization history. The patient has never had a blood transfusion. Mrs. R.K.B has been diagnosed with strep throat in the past.
Present Medication
She is currently on prescribed medication like Ibuprofen 400mg PRN for pains. She is also on Calcium Acetate 667mg once daily for bone formation. She also takes vitamin C 500mg once a day to boost her immune system.
Perception of Health
Mrs. R.K.B’s perception of her health condition is good as she feels she is healthy and good. Compared to the regular African Americans who struggle with high blood pressure, diabetes, and high cholesterol due to their sedentary lifestyle. Also, most African America the same age as Mrs. R.K.B do not take the time to visit the hospital because of a lack of insurance, or they feel they are healthy so, they do not need to visit the hospital. The patient has an allergic reaction to chloroquine, she stated it irritates her skin, and she swells around her eyes.
Present Illness
Mrs. R.K.B engages in vigorous exercise 4 times a week for 30 mins, and she tries to keep fit to be able to care for her family. Her last well-woman checkup was okay, which the nurse educator encouraged her to continue performing this checkup to prevent and review her reproductive health from time to time (Jarvis & Eckhardt, 2020). The patient currently is a nursing student so, she is aware of the implication of an unhealthy diet, and her salt intake is medium because she is knowledgeable of what a high intake of sodium can do to people mostly, African Americans. So, at this time of the visit, the patient has no illness.
Family Medical History
Her mother was diagnosed with high blood pressure at the age of 38, which motives her to try to live a healthy lifestyle to avoid high blood pressure. Her father has been diagnosed with a cataract of the eyes, which he is yet to perform surgery to remove the cataract, and her siblings have no significant health problems. Her mental health states she is stressed, and she stated schoolwork and trying to take care of her immediate family’s day-to-day activities was putting a lot of stress on her because she has two children.
Reason for Care
Mrs. R.K.B stated, she started her menstrual cycle at the age of 13, which is an ideal age. Her last menstruation was on September 19th, 2020. She states her period is every 24 days, and she had never had a rectal examination. The reason for her visit was for a well-woman checkup. I asked her if she would want a Pap smear done today, and she wanted to know what a Pap smear was? I explained, “it is a procedure to test for cervical cancer in women” (Pap smear – Mayo Clinic, 2019). And she accepted the Pap smear screening since her main aim for her visit was for a good woman checkup. Mrs. R.K.B was taking her health as her optimum priority.
Cultural Consideration
Due to her cultural belief, she stated she does not take alcoholic beverages, and at some period of the year, due to her religious beliefs, she fast. She explained she was a catholic, and during Lent, she avoids eating meat on Ash Wednesday and all the Fridays of Lent, and I documented that information in the system.
Review of Systems
When I went through the system, it stated she had been diagnosed with strep throat in the past. It was treated with some antibiotics, after which she was better. She has never had strep throat after the first incident.
Developmental Consideration
During the assessment, the patient weight, height, and size were appropriate for her age. Going through her records on the system, Mrs. R.K.B started her first menstrual cycle was at the age of 13 years, which is within the right age of development.
Psychosocial Consideration
Mrs. R.K.B, a mother of 2 children, talked about how much she loved spending time with her family. She talked about how her husband and the children supported her decision by going back to school.
HEENT (Head, Eyes, Ears, Nose, and Throat)
Before I got all the necessary information from Mrs. R.K.B, I started my assessment by first introducing myself to the patient. I verified with the patient if she was aware of what brought her to the hospital, which she was alert and oriented to the place and situation. Inspecting her face and it is symmetry with facial structures, her head is normocephalic without any lesions or infections noted. Patient two eyes are symmetrically placed, there are no infections to the eyebrows, eyelids, or eyelashes, there are no discharge, redness, or drainage noted. The patient has two ears, and they are both symmetrically placed looking at the patient ear. There is no redness, drainage, or discharge looking behind the ear. The patient nose is symmetric to other facial features, there are no wounds rash, or lesions noted. When I checked with the light, there is no foreign body, no inflammation or deformity noted. When inspecting the patient’s throat with a tongue blade, the uvula rises and falls at the midline.
Neck
When I inspected the neck for symmetry, I ensured Mrs. R.K.B’s neck was in the midline. I assessed her neck range of motion, palpated the lymph nodes, and I used a gentle circular motion to palpate the lymph nodes in front of the ear and, within the neck, I also palpated the thyroid gland for any abnormal findings, and everything was okay.
Respiratory
When inspecting Mrs. R.K.B, she is not using any accessory muscles. When I auscultated her anterior and posterior lung, it was clear to auscultation bilaterally. She has no scoliosis, Kyphosis, Lordosis, or no crackle sounds. The A/P diameter is less than transverse.
Cardiovascular System
When I placed the bell side to listen to her carotid artery, the carotid pulses one at a time was 2+ and no bruits noted, no jugular vein distension. Right Aortic intercostal space and the left intercostal space pulmonic S2 is greater than S1, Erb’s point S1 was greater than S2, the Tricuspid and Mitral were S1 greater than S2 which was within the normal range.
Neurological System
I began Mrs. R.K.B’s neurological assessment by assessing her level of consciousness. I assessed if she was alert, awake, and aware of the environment. She was oriented to person, time, situation, and place. Her facial expression, speech, and general mood and affect were appropriate to the situation. I assessed her appearance, posture, dressing, and grooming and it was appropriate.
Gastrointestinal System
The contour is flat, and the abdomen is symmetrical. She has an even skin color, and it is appropriate for the patient’s race. (Epigastric, Umbilical, and Suprapubic Areas) No bruits were auscultated to the epigastric, umbilical, and suprapubic areas. Her bowel sounds are normoactive in all four quadrants.
Musculoskeletal System
When assessing Mrs. R.K.B’s musculoskeletal system, I began with the inspection. I inspected the corresponding joints, structure, and function of each joint to determine if a full range of motion is present. I palpated the joint and skin to note temperature, musculoskeletal or muscular deformation, and it was okay. I assessed her range of movement by asking her to do an active range of motion like flexion, extension, abduction, adduction, and pronation, which she was able to perform.
Peripheral Vascular System
In this part of the assessment, I inspected and palpated her arms. I noted the color of her skin and nail beds, the temperature, texture, and turgor of the skin, and assessed for any lesions and edema. I assessed the patient for a capillary refill, and it was less than two seconds, I inspected and palpated her legs, and there was no swelling or lesions noted.
Needs Assessment
Going through her family health history, and as an African American, Mrs. R.K.B has a great chance of developing hypertension later in life. Her mother was diagnosed with high blood pressure at the age of 45 years. One health educational need for Mrs. R.K.B is to always monitor her blood pressure and to avoid smoking cigarettes or secondhand smoking. It states, “hypertension is the leading cause of death and disability-adjusted life-years worldwide. In the United States, hypertension accounts for more cardiovascular disease (CVD) deaths than any other modifiable risk factor which are second only to cigarette smoking as a preventable cause of death for any reason” (Carey & Whelton, 2018).
Mrs. R.K.B belongs to a nuclear family, which consists of her husband and two children, and that makes her very connected.
Conclusion
Mrs. R.K.B, at 25 years of age, was making the right decision of taking charge of her health and life, which most people her age would not take important, which makes her wise at that age.
Reflection
When Mrs. R.K.B arrived at the hospital at Sugarland for her well-woman check-up on September the 21st, 2020. Before starting with the interview with her, I made sure the environment was well lightening and quiet, with comfortable room temperature to make sure my patient was relaxed and able to trust I could provide her with proper care. When I began with the interview, she answered politely and calmly. She demonstrated high-level respect during the communication process. I interviewed her using an open-ended question which, enabled her to be open to discuss her health concerns and asked questions when needed. She was so comfortable discussing why she wanted to take charge of her health to be around and healthy for her family. “Driven by the patient’s reason for seeking care, history and symptoms, the process of targeting the physical assessment from the outset foregrounds inductive reasoning and clinical judgement” (Douglas et al., 2016). I also used therapeutic communication means to get tangible information from the patient, and the idea was to provide maximum healthcare for the patient, which made her trust me more. I noticed she sometimes avoided eye contact with me, and I asked if everything was okay. She made me understand her parent migrated to the United States from West Africa, the culture growing up as a child which she learned it was rude to look at anyone straight to the face. And I asked her what she preferred me to do during the interview process, and she stated nicely the way I conducted the interview was okay. I was happy she was comfortable explaining her cultural expression, and the interview process went well.
References
Jarvis, C., & Eckhardt, A. (2020). Physical examination & health assessment (8th ed.). St. Louis, MO: Elsevier.
Pap smear – Mayo Clinic. Mayoclinic.org. (2019). Retrieved 27 September 2020, from
https://www.mayoclinic.org/tests-procedures/pap-smear/about/pac-20394841
.
Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., & Gardner, G. (2016). Nursing
physical assessment for patient safety in general wards: reaching consensus on core skills. Journal of Clinical Nursing, 25(13-14), 1890-1900.
https://doi.org/10.1111/jocn.13201
Carey, R., & Whelton, P. (2018). Prevention, Detection, Evaluation, and Management of High
Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Annals of Internal Medicine, 168(5), 351.
https://doi.org/10.7326/m17-3203
2
Medical Health History
Name
Institutional Affiliation
Professor
Course
Date
Demographics
Name: N/A. Gender: Female. Age: 20s. Race/Ethnicity: Caucasian/White. Occupation: Student Nurse. Education level: The patient is in the final year of her undergraduate nursing degree studies. Primary language: English. Nutrition: normal weight. Blood Pressure: Normal. Reason for visit: Annual check-up. Generally, the patient is awake, alert, and lively. The patient has no allergies to most drugs except NSAIDS, which causes her nosebleeds. Also, she has no reactions to foods and most additives. She has no signs of acute distress or any mental condition. The patient indicated she had her last annual medical check-up in January 2020. She came seeking another check-up just to make sure her health is fine and stable.
Perception of Health
Being a nursing student in her final year of study, the patient understands what good health is and has a positive attitude towards a healthy lifestyle. The patient understands the importance of check-ups and believes it is not good to ignore them even when generally feeling okay. The patient indicated that she follows a daily exercise routine to keep her body fit and boost her health and immunity. Although the patient is in normal weight, she has been dieting whenever she feels like her weight could be increasing. She eats three light meals on an average day and two when dieting. The patient does not use caffeinated substances, tobacco, alcohol or drugs, and avoids frequent red meat consumption. The patient stated that she uses contraceptives to prevent pregnancy since she is sexually active. However, she did not provide specific information about the contraceptives she uses. The patient demonstrated signs of eyesight complications since she frequently experiences a headache when studying in a poorly lit room.
Past Medical History
The patient indicated that she contracted chickenpox in childhood before she was immunized against the disease in the year 2000. Chickenpox is a common infection caused by the virus varicella-zoster. The infection manifests in small, fluid-filled blisters on the skin that causes an itchy sensation on the patient. The disease also causes a light cough in some patients. The itching and blister rash usually appears between 10 and 21 days of exposure through close contact with an infected person or surface. The virus lasts for five to ten days on the victim’s body. While chickenpox is considered a mild disease, it can have serious effects and complications such as pneumonia, brain inflammation, bacterial infections on the skin and bloodstream, dehydration, and sometimes death. The patient was recently immunized against influenza, hepatitis, tetanus, and MMR. The patient had no history of other medical problems diagnosed by doctors before and had never had a surgery experience. Further, the patient stated that she had no blood transfusion or previous hospitalizations in her life. The patient has been using Cryselle, a family planning drug for birth control.
Family Medical History
The patient is single and lives with her parents and four siblings; three sisters and a brother. She is not aware of any significant health problems with either of them. Both parents are alive in their 40s and with no health complications that she could tell. The patient has no children yet. The patient’s grandparents, both paternal and maternal, are alive in their 60s-70s. Her maternal grandfather has been suffering from COPD and CHF for the last few years. The patient is not aware of her paternal grandparents’ medical conditions and that of her maternal grandmother. The family medical history is essential in medical examination since it provides a background for evaluating any complications that may be genetic or otherwise related to the family (Bennett, 2019).
Review of Systems
Skin/hair/nails: The patient skin is white and consistent with her race/ethnicity. The skin is smooth; no lesions or bruises and has a warm temperature. Her hair has normal color and texture. The nails are pink, short, intact, normal in shape, and clean. Their capillary refill time is approximately 2 seconds. Generally, the skin, hair, and nails appear normal.
Head and neck: The patient’s head is normocephalic with no signs of injury. The skull and skin show no signs of infestation. Her face is symmetrical, without bruises, tattoos, or piercing except for a healed scar on the left side of the forehead, which she explains she knocked against the door two years ago. The neck has a symmetrical shape and indicates no signs of pulsations and masses. The lymph nodes feel and look normal with no inflammations.
Eyes, ears, nose, and mouth: The eyes are symmetrical and with no discharges. However, the patient indicates blurred vision, discomfort in the morning and at night in the left eye, difficulty with night vision, and some light headaches. The signs indicate stigmatism in the left eye. The left and right ears look normal, and the hearing also appears normal. The ears also look clean on the inside and outside. The nose is symmetrical, in the right position, and also proportional to other parts. The nose is clean and has no discharges. Her dentation looks normal, with all teeth intact and white. The lips are moist, in their right color, and the gum is well cared for. The cardiovascular, respiratory, gastrointestinal, and urinary systems appear normal with no signs of infections or any form of damage.
Developmental Considerations
The patient has grown up in a stable family and has not experienced major emotional constraints. The patient has been emotionally stable over the longest part of her life, owing to both her parents’ very stable upbringing. She is in her early adulthood, and this indicates she is in the intimacy vs. isolation stage of Erickson’s eight stages of development (Jarvis, 2016). At the intimacy vs. isolation stage, the patient is concerned about establishing long-term relationships. Her physical and emotional well-being are essential, which may explain why she makes for annual medical check-ups. The patient has a positive attitude towards life, self-love, and strong self-esteem. Given that she is still in school pursuing her career, the patient has a bright future and a strong positive sense of life and healthy living.
Cultural Considerations
The patient has a close connection and ties to her culture. She believes that her family is the most important social institution and defines much of what she does. The patient believes that faith is a central pillar upon which life is founded. Therefore, religion is critical in influencing her choices. The patient was born and brought up in America and has grown up among rich, educated people, which informs her health concerns and the regular check-ups. Clinical assessment such as patient observation, testing, physical examination, and recording their history is influenced by cultural factors (Gopalkrishnan, 2018).
Psychosocial Considerations
The psychosocial assessment helps the nurse to determine if the patient is in a proper mental state or is mentally ill. The patient appears to be psychologically strong and emotionally stable. She has minimal responsibilities at home and little to care about, and hence she is fulfilled with her life. She has a strong family connection and hence social and emotional support. However, the patient has experienced stress a few times due to academics pressure and her search for a relationship identity. Generally, the patient has had no major psychological problems in her life.
Collaborative Resources
The patient has lived amongst a very supportive group of people. Her parents have supported her both financially and psychologically in her academics. Besides, the parents have been her source of comfort during difficult circumstances, and in times, she needs to make complex decisions. The patient has also established a strong bond with her teachers at school, and they give her council whenever she approaches them.
Reflection
The patient visited the clinic early in the morning before activities increased with the number of patients visiting. The early visit offered us an opportunity to engage at length, drawing more details from the patient and her medical files. The patient shared the information comfortably, motivated by the perceived confidentiality since we were alone in an enclosed room. The interview began with an assurance that the information shared would be handled with the utmost confidentiality.
With both of us being White Americans, there were no barriers in communication. We both used the English language. Besides, I gave her time to express herself with minimal interruptions. However, it was difficult for the patient to understand some of the medical terms that I used in our conversation. The success of the assignment was evidenced by the open sharing of the medical history of the patient. Generally, the assignment did not have any unanticipated challenge except the patient’s reluctance to talk at the beginning of our engagement. However, I wished I had more information on family medical treatment history, but the patient could only share that of a few members. Next time I will involve a close member of the family, preferably older than the patient. Such a member can enrich the information given by the patient and obtained from health records. The experience was different from classwork since it allowed me to the diagnostic process in healthcare from practical experience.
References
Bennett, R. (2019). Family Health History. Medical Clinics of North America, 103(6), 957-966. https://doi.org/10.1016/j.mcna.2019.06.002.
Gopalkrishnan, N. (2018). Cultural Diversity and Mental Health: Considerations for Policy and Practice. Frontiers in Public Health, 6.
https://doi.org/10.3389/fpubh.2018.00179
.
Jarvis, C. (2016). Physical Examination and Health Assessment. Elsevier. 7th Edition. St. Louis, Mo.
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Dates
R
evised:
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| enter text. |
enter text.
enter text.
enter text.
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HEAL
T
H HI
S
TORY
Q
UESTIONNAIRE
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All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.
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Initials:
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Race/Ethnicity: Caucasian/White
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☐
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M
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F
Age
20s
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Occupation: Student Nurse
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Marital status:
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☒ Single ☐
P
artnered ☐ Married ☐ Separated ☐ Divorced ☐ Widowed
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Reason
for visit: Annual check-up
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Perception of health:”I’m just here for a yearly check-up”
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Date of last physical exam:
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6/11/2020 |
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Source of information: Patient
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Reason for seeking care: yearly check-up
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Present health or history of present illness:
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P
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enter text.
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Q
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| enter text. |
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R
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enter text.
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S
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enter text.
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T
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enter text.
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PERSONAL HEALTH HISTORY/Past health
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Childhood illness:
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Measles Mumps Rubella Chickenpox Rheumatic Fever Polio
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Immunizations and dates:
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☒Tetanus
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June 2016 |
☐Pneumonia
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N/A
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☒Hepatitis
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| August 2020 |
☒Chickenpox
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June 2000 |
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☒Influenza
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August 2020
☒MMR Measles, Mumps, Rubella
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August 2020
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List any medical problems that other doctors have diagnosed
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enter text.
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Surgeries
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Year
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Reason
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Hospital
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N/A N/A N/A
enter text.
enter text. enter text.
enter text. enter text. enter text.
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Other hospitalizations
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Year
Reason
Hospital
enter text. enter text. enter text.
enter text. enter text. enter text.
enter text. enter text. enter text.
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Have you ever had a blood transfusion?
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☐
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Yes
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☒
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No
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Please turn to next page
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List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
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Name the Drug
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Strength
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Frequency Taken and Reason
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| Cryselle |
N/A
Every day; Birth Control |
enter text. enter text. enter text.
enter text. enter text. enter text.
enter text. enter text. enter text.
enter text. enter text. enter text.
enter text. enter text. enter text.
enter text. enter text. enter text.
enter text. enter text. enter text.
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Allergies to medications, latex, food, iodine/betadine
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Name the Drug
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Reaction You Had
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| NSAIDS |
Nose bleed |
enter text. enter text.
enter text. enter text.
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HEALTH HABITS AND PERSONAL SAFETY
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All questions contained in this questionnaire are optional and will be kept strictly confidential.
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Exercise
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☐Sedentary (No exercise)
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☐Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
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☒Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
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☐Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
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Diet
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Are you dieting?
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Yes
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No
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If yes, are you on a physician prescribed medical diet?
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☐
Yes
☒
No
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# of meals you eat in an average day? 2 meals
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Rank salt intake
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☒Hi
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☐Med
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enter text.Low
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Rank fat intake
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☐Hi
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☐Med
X Low
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Caffeine
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None
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☒Coffee
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☐Tea
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enter text.Cola
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# of cups/cans per day? ☒
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Alcohol
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Do you drink alcohol?
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☐
Yes
☒
No
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If yes, what kind? enter text.
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How many drinks per week? enter text.
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Are you concerned about the amount you drink?
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☐
Yes
☒
No
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Have you considered stopping?
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☐
Yes
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No
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Have you ever experienced blackouts?
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☐
Yes
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No
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Are you prone to “binge” drinking?
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☐
Yes
☒
No
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Do you drive after drinking?
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☐
Yes
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No
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Tobacco
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Do you use tobacco?
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☐
Yes
☒
No
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☐Cigarettes – pks./day N/A
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☐Chew – #/day N/A
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☐Pipe – #/day N/A
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☐Cigars – #/day N/A
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☐ # of years N/A
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☐Or year quit N/A
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Drugs
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Do you currently use recreational or street drugs?
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☐
Yes
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No
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Have you ever given yourself street drugs with a needle?
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☐
Yes
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No
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Sex
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Are you sexually active?
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☒
Yes
☐
No
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If yes, are you trying for a pregnancy?
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☐
Yes
☒
No
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If not trying for a pregnancy list contraceptive or barrier method used: Oral Contraceptives
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Any discomfort with intercourse?
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☐
Yes
☒
No
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Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
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☐
Yes
☒
No
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Personal Safety
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Do you live alone?
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☐
Yes
☒
No
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Do you have frequent falls?
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☐
Yes
☒
No
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Do you have vision or hearing loss?
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☐
Yes
☒
No
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Do you have an Advance Directive and/or Living Will?
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☐
Yes
☒
No
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Would you like information on the preparation of these?
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☒
Yes
☐
No
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Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?
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☐
Yes
☒
No
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FAMILY HEALTH HISTORY
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Age
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Significant Health Problems
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Age
Significant Health Problems
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Father
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| 40s |
N/A
Children
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☐M
☐ F
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enter text.
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Mother
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40s N/A
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☐M
☐ F
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enter text.
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Sibling
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☐M
☒ F
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N/A
☐M
☐ F
enter text.
☐M
☒ F
N/A
☐M
☐ F
enter text.
☐M
☒ F
N/A
Grandmother
Maternal
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| 70s |
N/A
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☒M
☐ F
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N/A
Grandfather
Maternal
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70s
COPD, CHF |
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☐ M
☐ F
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enter text.
Grandmother
Paternal
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70s N/A
☐M
☐ F
enter text.
Grandfather
Paternal
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60s |
N/A
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MENTAL HEALTH
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Comments
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Is stress a major problem for you?
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☒
Yes
☐
No
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Do you feel depressed?
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☐
Yes
☒
No
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Do you panic when stressed?
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☒
Yes
☐
No
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Do you have problems with eating or your appetite?
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☐
Yes
☒
No
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Do you cry frequently?
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☐
Yes
☒
No
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Have you ever attempted suicide?
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☐
Yes
☒
No
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Have you ever seriously thought about hurting yourself?
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☐
Yes
☒
No
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Do you have trouble sleeping?
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☐
Yes
☒
No
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Have you ever been to a counselor?
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☐
Yes
☒
No
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WOMEN ONLY
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Age at onset of menstruation: 12 years
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Date of last menstruation: 12-17-2020
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Period every month for abt 5 days
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Heavy periods, irregularity, spotting, pain, or discharge?
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☒
Yes
☐
No
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Number of pregnancies N/A Number of live births N/A
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Are you pregnant or breastfeeding?
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☐
Yes
☒
No
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Have you had a D&C, hysterectomy, or Cesarean?
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☐
Yes
☒
No
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Any urinary tract, bladder, or kidney infections within the last year?
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☐
Yes
☒
No
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Any blood in your urine?
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☐
Yes
☒
No
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Any problems with control of urination?
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☐
Yes
☒
No
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Any hot flashes or sweating at night?
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☐
Yes
☒
No
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Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?
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☐
Yes
☒
No
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Experienced any recent breast tenderness, lumps, or nipple discharge?
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☐
Yes
☒
No
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Date of last pap and rectal exam? 10/2020
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MEN ONLY
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Do you usually get up to urinate during the night?
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☐
Yes
☐
No
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If yes, # of times enter text.
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Do you feel pain or burning with urination?
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☐
Yes
☐
No
Any blood in your urine?
☐
Yes
☐
No
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Do you feel burning discharge from penis?
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☐
Yes
☐
No
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Has the force of your urination decreased?
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☐
Yes
☐
No
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Have you had any kidney, bladder, or prostate infections within the last 12 months?
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☐
Yes
☐
No
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Do you have any problems emptying your bladder completely?
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☐
Yes
☐
No
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Any difficulty with erection or ejaculation?
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☐
Yes
☐
No
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Any testicle pain or swelling?
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☐
Yes
☐
No
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Date of last prostate and rectal exam? enter text.
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|
review of systems
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|
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
|
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☐
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Skin/Hair/Nails N/A
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☐
Respiratory N/A
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☐
Neurologic N/A
|
☐
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Head/Neck N/A
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☐
Cardiovascular N/A
|
☐
Recent changes in Weight N/A
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☒
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Eyes Stigmatism in left eye
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☐
Peripheral Vascular N/A
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☐
Recent changes in Energy level Normal
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☐
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Ears N/A
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☐
Gastrointestinal N/A
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☐
Sleep/rest pattern N/A
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☐
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Nose N/A
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☐
Urinary N/A
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☐
Other pain/discomfort: N/A
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☐
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Mouth/Throat N/A
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☐
Musculoskeletal N/A
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