Health History and Physical Assessment
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Health History and Physical Assessment
Running head: HEALTH HISTORY AND PHYSICAL ASSESSMENT 1
HEALTH HISTORY AND PHYSICAL ASSESSMENT 6
Health History and Physical Assessment
Chamberlain College of Nursing
NR 304: Health Assessment II
Health History and Physical Assessment
The person whose health was assessed will be referred to as AG throughout the paper.
AG is a 41-year-old African-American female student at Chamberlain University College of Nursing. She is married and has three children, among ages six, four, and two.
Reason for Seeking Care
AG came into the office for routine annual check-up.
Her blood pressure is 132/70 and considered as the stage of pre-hypertension. Being an African-American adult, she is at risk of developing hypertension (Jarvis, 2015, p.137). A.G. confirms that her blood pressure is a little bit high, but she denies any pain and concern at this time. The main need of her is to educate her on further prevention hypertension and signs and symptoms of further complications.
Perception of Health
The client perceived, “I consider myself as a healthy person although my blood pressure slightly high, and I am currently in a good health.” She added that “daily exercise helps enhance an individual’s health.” Therefore, she engages in regular mild exercise every day such as climbing home stairs, doing house chores, and taking care of her three children. Furthermore, she avoids consumption of alcohol and tobacco usage. Finally, she limits her caffeine intake to one cup of coffee or one cup of tea per day to avoid addiction. Nevertheless, she identifies medium intake of fat and frequent breakfast skipping.
Past Medical History
AG denies any childhood illness, injury, or accident. She states she does not have any signs of allergies or chronic disease. She has been taking birth control pills for one year without other prescriptions or over-the-counter medications in current. The last time she sought health care services was on 10th January 2019. She mainly visited it for physical assessment. She has not suffered from any mental condition throughout her lifetime. The only reason she has been hospitalized 3 times is to give births to her 3 children; they are all healthy as well. Nonetheless, all of her immunizations are up-to-date; she has been immunized against MMR (measles, mumps, rubella), tetanus, hepatitis, influenza, chickenpox, pneumonia, and no TB screen test.
Family Medical History
Most of her family members have been diagnosed with no significant health problems, and their lifespans ranged from 75 to 90 years old except her mother who died of falling at the age 75; according to the text book, older adults increase risk of falling (Jarvis, 2015, p. 616). However, her father and other three sisters have not been diagnosed with any critical condition.
Review of Systems
General Health. Reports usual health “OK.” No recent weight change; no fatigue, weakness, fever, sweats.
Skin. No change in skin color, pigmentation, or nevi. No pruritus, rash, lesions. No history of skin disease.
Hair: No loss, change in texture.
Nails: no change.
Self-care: Stays in sun “as much as I can.” No use of sunscreen. Goes to tanning beds at hair salon twice/week during winter.
Head. No unusually frequent or severe headaches; no head injury, dizziness, syncope, or vertigo.
Eyes. No difficulty with vision or double vision. No eye pain, inflammation, discharge, lesions. No history of glaucoma or cataracts. Wears no corrective lenses.
Ears. No hearing loss or difficulty. No earaches; no infections now or as child; no discharge, tinnitus, or vertigo.
Self-care: No exposure to environmental noise; cleans ears with washcloth.
Nose. No discharge; has 2 or 3 colds per year; no sinus pain, nasal obstruction, epistaxis, or allergy.
Mouth and Throat. No mouth pain, bleeding gums, toothache, sores or lesions in mouth, dysphagia, hoarseness, or sore throat. Has tonsils.
Self-care: Brushes teeth twice/day, no flossing.
Neck. No pain, limitation of motion, lumps, or swollen glands.
Breasts. No pain, lump, nipple discharge, rash, swelling, or trauma. No history of breast disease in self, mother, or sister. No surgery.
Self-care: Does not do breast self-examination.
Respiratory. No history of lung disease; no chest pain with breathing; no wheezing or shortness of breath. Colds sometimes “go to my chest”; treats with over-the-counter cough medicine and aspirin. Occasional early-morning cough, nonproductive. Works in well ventilated tavern.
Cardiovascular. No chest pain, palpitation, cyanosis, fatigue, dyspnea with exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema. No history of heart murmur, hypertension, coronary artery disease, or anemia.
Peripheral Vascular. No pain, numbness or tingling, or swelling in legs. No coldness, discoloration, varicose veins, infections, or ulcers. Legs are equal in length.
Gastrointestinal. Appetite good with no recent change. No food intolerance, heartburn, indigestion, pain in abdomen, nausea, or vomiting. No history of ulcers, liver or gallbladder disease, jaundice, appendicitis, or colitis. Bowel movement 1/day, soft, brown; no rectal bleeding or pain.
Self-care: No use of vitamins, antacids, laxatives.
Urinary. No dysuria, frequency, urgency, nocturia, hesitancy, or straining. No pain in flank, groin, suprapubic region. Urine color yellow; no history of kidney disease.
Genitalia. Menarche age 16. Last menstrual period July 15. Cycle usually q 28 days, duration 2 to 3 days, flow small amount, no dysmenorrhea. No vaginal itching, discharge, sores, or lesions.
Sexual health. Uses birth control pills to prevent pregnancy
Musculoskeletal. No history of arthritis, gout. No joint pain, stiffness, swelling, deformity, or limitation of motion. No muscle pain or weakness.
Self-care: walking or mild exercising every day for 30 minutes
Neurologic. No history of seizure disorder, stroke, fainting. No weakness, tremor, paralysis, problems with coordination, difficulty speaking or swallowing. No numbness or tingling. Denies any suicidal ideation or intent during adolescent years or now.
Hematologic. No bleeding problems in skin; no excessive bruising. Not aware of exposure to toxins, never had blood transfusion, never used needles to shoot drugs.
Endocrine. No increase in hunger, thirst, or urination; no problems with hot or cold environments; no change in skin or appetite; no nervousness.
AG has experienced normal growth and development since childhood to today because she has not encountered any medical issue yet. She was able to interact well with her peers during her younger age, which also contributed to her development. In addition, the absence of any disease up-to-date has enabled her to pursue her nursing career at Chamberlain University with no problems. According to Erickson’s theory, AG is in the stage of generativity versus stagnation of her development (Edelman, 2018, p. 607). At the age 41, she has still been chasing for her nursing career at Chamberlain University but performing her role as a student excellently in school. I asked if she felt any stagnation or vulnerability being the oldest student in class, she responded, “I would not alter anything about my life. I am blessed because I found a very good man for myself. I could not be back to school without his encouragement and support. My husband is truly helpful.” AG has been married to her husband for 6 years and they have three healthy, lovely children together. I can feel her happiness, so I believe that AG is meeting the standard milestone for her age and the stage in Erickson developmental stages theory.
AG was raised and grown up in Asmara, Eritrea. She came to the United States 9 years ago thus English is her second language. Her mother language is Tigrigna. Even though she has learned to speak, read, write in English, and currently being a student nurse, she states that she still faces language barrier since her accent is so strong and hinder that can lead to misunderstanding sometimes. She identifies herself as Christian, but she is neither attend regular practices nor go to church often because of her busy schedule with being a full-time student and a mother of three children. She was raised and taught by her parents that illnesses cause by disharmony with nature. Thus, her family members tend to seek traditional remedies such as using herbs and roots, or to see spiritualists such as the Old Lady (Jarvis, 2015, p.19); in contrast, she tends to seek to doctors’ office and takes prescribed medications, and that she usually follows her regular checkups as ordered by her doctors. Therefore, AG does not have any cultural issue that a health care provider needs to be considered with except she may need a medical interpreter who is fluent in her language to support her with accuracy of communication and her satisfaction every time she seeks for health care at a medical clinic. According to Jarvis, trained interpreters help improve total health outcomes, improve use of primary care, and increase client satisfaction. Their use may also result in a cost savings and reduced rate of complications (Jarvis, 2015, p. 44).
AG beliefs in common theory that cancer is genetic and can be passed from parents to their children, so she confidently states that she inherited a good gene from her parents because none of them were diagnosed with chronic diseases or cancers while they were alive; their deaths were from aging and falling. Nevertheless, she indicates that she has been feeling stress since she started classes in nursing school; however, she has learned how to release her anxiety by trying not to procrastinate in her study for exams and doing homework before due days. Besides, the loss of her closet family members as her mom and dad makes her sad; the saddest part is that her relationship with her other three sisters seems not to be as close as before since their parents are passed away, so she really misses the love of her sisters who used to share with most of her secrets as well as to consult before deciding important things in life.
Overall, throughout her life, AG has been supported by various parties when she needed any type of support, including both psychological and financial support. Her family members and friends have given her psychological support any time she has an issue that is disturbing. In current, her husband has been supporting her with her healthcare insurance, her school fees, and cater for other expenses as well.
Objective Data – Physical Assessment
I begin to introduce myself and explain that I am here to do head to toe assessment on her. Then I start doing hand hygiene and ask her to verify her name and date of birth, plus asking her where she is and who is the current president of the United State. She appears alert and oriented times three. She states that she has not been experiencing any allergy so far and denies any pain at the moment.
Then I inspect her general appearance. Her skin is appropriate with her age and skin color is appropriate with her ethnicity as well. She shows no signs of acute distress and no visible devices or equipment. Her posture is erect. Her nutrition is adequate and does not show obvious deformities. Her behaviors appear appropriate with situation as well. When I check her temperature by touching her hands, it is warm and dry to touch. Her nails are pink, normal shape and contour. Capillary refill is within 2 seconds. There is no signs of tenting when I check her skin turgor so she is not dehydrated.
Next, I take her vital signs. Her temperature is 96.2 degree. Pulse is 47. Respiration is 18. Pulse oximetry is 99. Blood pressure is 132/70; I noted that her blood pressure is in the stage of prehypertension.
Then I move on inspecting her HEER (head, eyes, ears, nose, and throat). I palpated her head and asked if she felt painful or irregular sensations; she said she had no pains. Her head appears normalcephalic without lesions or infestation. Her eyes are symmetrical without any lesions, discharge, or infestation of eyebrows, eyelids, and eyelashes. Her conjunctiva is moist, and Sclera is white. At this point, I also test the functions of her Cranial Nerve II, III, IV, and IV; they are all intact because she was able to read the card that I provided to her thus she passed my confrontation test; I noted that her PERRLA is well noted because while I was shining the penlight to each of her eye, her pupils appeared equal, round, reactive well to light and accommodation, and she was able to move her eyes parallelly following my certain directions, and that she also shows no signs of ptosis or nystagmus. Her ears appear symmetrical; there is no signs of skin breakdown, welling, redness, or discharge, and she has 2 piercings and 1 piercing each ear, nonpainful tragus. Her hearing is intact bilaterally when I inspect her Cranial Nerve VIII by performing the whisper test. Her nose is in midline without foreign bodies or deviated septum, and bilateral patency is also noted, and that her Cranial Nerve I is intact as well because she can identify the smell of coffee when covering each of her nares one at a time while closing her eyes. Her mouth and lips are pink without signs of cracking, her palates are intact, her mucus membrane is pink without signs of dental cavity or odor, and that there is no lessons in her mouth; I conclude her Cranial Nerve IX, X, and XII are intact because when I test her with the tongue blade, she does not have any problem with swallowing, her uvula is midline, normal rise and fall of the tongue, and her tongue protrudes in midline without tremors, and that she was able to say “light, tight, dynamite,” clearly and distinctly. Then, I test her Cranial Nerve V by asking her to close her eyes, clench her teeth and touching her with the cotton ball to see if her felt any sensation and the result is a yes, and her jaw strength is equal bilaterally as well. Finally, I test her Cranial Nerve VII by asking her to smile, frown, and puff her cheek, and the result is that her facial muscles are intact and symmetric.
Next, I inspect her neck; it appears symmetrical. Trachea is midline. Then I palpated her lymph nodes such as preauricular, posteriorauricular, occipital, jugulodigastric, submandibular submental, and supraclavicular; I asked if she felt any tenderness and she said no, so I noted that her lymph nodes are nonpalpable and nonpainful. At this point, I also test her Cranial Nerve XI by shrugging her shoulders against resistance of my hands while I was pressing them down; her shoulder movements appear equally strong on both sides.
Her respirations are within normal. Anterior-Posterior diameter is less than transverse diameter. There are no signs of scoliosis, kyphosis, or lordosis posteriorly. When I palpated her chest and back, she states she did not feel any tenderness. There are no signs of irregular masses as well. I asked her to cross her arms over her shoulders and say “nighty-nine” every time I touch her back with my palms, her tactile fremitus was present and normal. Her chest expansion is symmetrical. Lastly, I auscultate her lung fields in eight positions bilaterally at the chest, nine positions bilaterally at the back and having her taking a deep breath each time I move my stethoscope. I noted that all her lung fields are clear times all lobes with no adventitious sounds.
I move on to assess her cardiovascular system. I begin by auscultating along the Z pattern of the five cardiac points which are the aortic valve, the pulmonic valve, the Erb’s point, the tricuspid valve, and the mitral valve with the diaphragm of my stethoscope. As I move my stethoscope to the mitral valve which is also called the apical pulse, I palpate her radial pulse and listen to her apical pulse at the same time for 60 seconds; the result is that they are equal and regular with no pulse deficit is noted. Then I redo listening to the five cardiac points but with the bell of the stethoscope; there is no murmur noted at these points as well. I then palpate the carotid pulses one at time to assess for regular rates and rhythms; her carotid pulses are equal and regular bilaterally. Finally, I make her bed a 45 degree and ask her to lie down and that shine the light to her neck to inspect for her jugular venous pulse, there is no jugular venous distention noted.
I assess her gastrointestinal system after that. I begin by having AG lie supine. I then lifted her shirt so I could fully inspect her abdomen I. I noted the skin to have equal color distribution, no lesions or surgical scars present. I do not see the presence of stretch mark on her lower abdomen. Her contour is flat, and no pulsations is noted. I then auscultate the four abdominal quadrants, beginning with the right lower quadrant moving to the right upper, to left upper, finishing with the left lower. I noted active bowel sounds in all quadrants. I then lightly palpated the abdomen in all quadrants, assessing for muscle guarding, rigidity, large masses, and tenderness. AG states that she feels no pain during palpation. Finally, I listen to adventitious sounds with the bell of my stethoscope at her epigastric, umbilical, and suprapubic areas; there is no bruits noted as well.
Next I assessed the extremities. I began with the upper extremities, looking at the skin, noting the normal distribution and color. I then inspected size and contour of the shoulders, elbows, and wrists, bilaterally. I then palpated each of these joints bilaterally, to which AG stated no pain. I then range of motion in the shoulders by having her flex up, extend, raise her arms laterally, touch her palms together above her head, and internally and externally rotate her shoulders. She demonstrated no pain and complete range of motion. I had her perform these movements again, but against my resistance to test muscle strength, which was equal and strong bilaterally. I then assessed her elbow joints by bending and straightening her elbow, once freely to test range of motion and once against my resistance to test muscle strength. She had full range of motion and equal and bilateral strength. I then had AG bend her hand up and down at the wrist, bend her fingers up and down, spread her fingers apart, make a fist, and touch her thumbs with each of her fingers. Range of motion was normal. I then assessed her muscle strength having her flex her wrist against my resistance, where she demonstrated strong bilateral muscle strength.
I then assessed her lower extremities. I inspected and palpated her hips, knees, feet and ankles the same as I did for the upper extremities. I then assessed range of motion in her hips, by having her supine I had her raise each leg with knees extended, bend each knee to chest while keeping other knee straight, swing each leg laterally then medially. When standing, I had her swing her leg straight back behind her body. Range of motion was normal. I assessed knee range of motion by having her bend each knee, extend each knee, and during ambulation I assessed her knees. I also performed a special test for meniscal tears called the McMurray test. I stood on her affected side (right) and held her heel and flexed her knee and hip. With my other hand on her knee and fingers on the medial side I rotated her leg in and out to loosen the joint. I then externally rotated the leg, pushing inward stress on the knee. I then slowly extended the knee, and I felt a “click” which is indicative of a meniscus tear. Finally, I assessed her ankles and feet. I had AG point her toes down, up, turn her feet out and in, and flex and straighten her toes. I then had her perform the same movements against my resistance. I then palpated a dorsalis pedis pulse bilaterally in both feet. The finding was normal and regular rate and rhythm, and symmetrical bilaterally.
I assessed AG spine, beginning with inspection. I inspected the skin, noting the even color and distribution. I then noted the straightness of her spine, and there was no scoliosis, kyphosis, or lordosis present. From inspecting from the side, I noticed the normal curvature of spine, normal convex thoracic curve and concave lumbar curve. I then palpated the spinous processes, which were straight and non-tender. I assessed range of motion by having AG bend forward and touch her toes, bend sideways, backwards, and twist. I noticed full range of motion in all aspects.
I assessed AG gait and range of motion while ambulating by having her walk a few steps and turn around and walk back. She demonstrated this very easily and I saw no visible pain or discrepancies. I then had her stand in front of me with her eyes closed and feet together (Romberg Test), where she demonstrated no swaying to the side and maintained her balance. I assessed her sensory function by having her shut her eyes and I lightly touched her forehead, cheeks, chin, upper and lower extremities, having her vocalize when she feels me touching her. Her responses were immediate with my touches. I was unable to assess her deep tendon reflexes due to lack of reflex hammer for personal use.
Finally, I concluded my assessment on AG, I reassessed her pain level, which she stated she was still in no pain, I offered her comfort measures and asked her if there was anything else I could do for her, I thanked her and I performed hand hygiene with some hand sanitizer.
- 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.
- ADD two peer-reviewed journal articles that provide evidence-based support for the health teaching needs you have identified.
Nurses use reflection to, mindfully and intentionally, examine our thought processes, actions, and behaviors in order to better evaluate our patients’ outcomes. You have interviewed an individual, conducted a head-to-toe physical assessment, and identified at least two health teaching needs. You have also located within the literature evidence-based support for the teaching that will be used to address the individual’s health education needs. As you formulate your findings in writing within this assignment, it is time to turn your attention inward. The final element of this assignment is to write a reflection that describes your experience.
- Be sure your reflection addresses each of the following questions. a. How did this assignment compare to what you’ve learned and expected? b. What enablers or barriers to communication did you encounter when performing a health history and physical exam? How could you overcome those barriers? c. Were there any unanticipated challenges encountered during this assignment? What went well with this assignment? d. Was there information you wished you had available but did not? e. How will you alter your approach to a obtaining a health history and conducting a physical examination the next time?
Jarvis, C. (2015). Physical Examination and Health Assessment. St. Louis, MO: Elsevier Health Sciences.
Edelman, E. C., & Kudzma, E. C. (2018). Health promotion throughout the lifespan (9th ed.). St. Louis, Missouri: Elsevier.
The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.
The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.
Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met.
More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided.
Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration.
Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met.
The background and/or significance are missing. No search history information is provided.
Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration.
There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met
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