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NR302 Health Assessment I

NR302 Health Assessment I

Sample Answer 

NR302 Health Assessment I

Demographic Data

Name :DG.

Age: 30 years.

YOB: 1990.

Occupation: company worker.

Education Level: Bachelor’s Degree.

Primary Language: English with a German background.

Nutrition: Currently seeking nutritional support since he is overweight.

Overall, the patient is weak and is brought into the hospital reception in a wheelchair. He has no signs of nervousness, has an upbeat personality, and does not have slurred speech. The patient is also well-groomed.

Past Medical History

The patient was hospitalized three years ago with a history of fever, depression, and severe headaches. He does not have any known allergies to food, drug, or insects. He is currently on the following medications metoprolol 100mg p/o and Prozac 20mg p/o, which he has been taking for the last six months

Family and Social History

The patient’s mother died of hypertension at the age of 70. The medical history of the father is unknown. There is no known family history of cancer. The patient is employed in a factory and is separated, and has one daughter whom he is allowed to see over the weekends. He is also depressed and feels alone, neglected, and isolated. Lastly, he denies past or present history of drug, alcohol, or tobacco usage.

Physical Exam and ROS

The patient is wheeled to the hospital’s reception, looking sick and weak. He also looks fatigued and depressed.

Review of Systems: Head to Chest

Physical Assessment: Skin, hair, and nail assessment.

Skin- the color is normal, and no redness or pallor; the texture is soft and smooth, and the temperature is warm. When the skin is pinched, it returns immediately to its original position with good skin turgor. There is no swelling, pitting, or edema. There are no skin lesions detected. Hair- the texture is fine and pliant. There are no presence or signs of parasitism, scaling, or dandruff.

Nail- nail beds are pink; the shape is round, hard, and immobile with a capillary refill of less than 3 seconds.

Head, Face, Neck Assessment:

Head- symmetrical in shape and round.

Face- symmetrical, centered head position.

Neck- smooth, controlled movements. Lymph nodes feel smooth and moveable with no nodules or lumps. Thyroid is easily movable and no sign or feeling of a goiter or nodule.

Eye Assessment:

Eyes are symmetrical. Eyelid margins are moist and pink. Conjunctiva is clear, no visible discharge. Sclera is white. Cornea is transparent, smooth, and moist. Iris are round and equal in shape, color is black. Lens are clear. Pupils are round, equal, reactive to light, and accommodative. Red light reflex is good with reddish-orange and healthy retinas. Pupillary response is equal. Last vision exam was two months ago.

Ear, Nose, Mouth Throat, and Sinus Assessment:

External ears are of equal size and symmetry. No tenderness or pain on palpation. Auditory canal is free of wax. Eardrums are pearly gray. Passed a whisper test on both sides. Lips are red and dry. Oral mucosa is pink and moist. Tonsils pink, uvula, and tongue midline. Dentition is good with 3 visible cavities that were fixed. Nose is symmetrical and, turbinates are pink, the septum is midline with no discharge. Sinuses are not tender.

Respiratory and Cardiac Assessment:

Chest rise is equal and unlabored. Chest rise is symmetrical, and percussion and auscultation is normal and equal, with no signs of tenderness or pain. Tactile fremitus is equal with no abnormalities. Auscultation of 5 landmarks of the heart was normal. APETM, as well as apical pulse correlating with the radial pulse. Carotids were normal with no sound of bruys and no presence of JVD.

Developmental Considerations

As per Erikson’s eight stages of development, the patient should be in the intimacy vs. isolation stage. I believe that my patient is in this stage and has been successful with it. My patient is happily married with three kids and has successfully worked toward a long-term relationship and built that sense of commitment.

Cultural Considerations

Due to the patient’s fair-toned skin, she is at a higher risk for developing skin cancer and should limit the amount of burns over her life time as well as practice wearing sunscreen daily. The patient is of Italian decent, and due to family dietary concerns or high carbohydrate and high-fat diets, there is an increased risk of being obese.

Psychosocial Considerations

Patient is a stable 37-year-old female with no considerable psychosocial considerations, although the patient does have the stress of self-concept and body image from being over-weight. Patient doesn’t have any present or past psychological issues.

Differential diagnosis

Gastric ulcers, colorectal adenocarcinoma, intestinal obstruction, GERD, depression or anxiety-related illnesses, pancreatitis. Continue Prozac p/o. Provide psychological therapy alternatives. Administer metoprolol 100mg per oral six hourly for the treatment of hypertension

Plan

Colonoscopy. If a colonoscopy reveals colon cancer, the patient is to be referred to a gastrointestinal oncologist. Administer Metamucil or a laxative to treat constipation.

Reflection

We were speaking in the same language as the patient. However, some terminologies used by the patient were not clear to me. To improve the communication process, I implemented active listening by improving my concentration on communication. I mobilized all the senses used for the perception of both verbal and nonverbal cues. Listening helped me to accurately get and record the vital signs of the patient as well as make clinical judgments.

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Question 


NR302 Health Assessment I

RUA: Health History Guidelines
Purpose
Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the individual
through the collection of both subjective and objective data. 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 subjective assessment
data, synthesizing the data, and on identifying health/wellness priorities based on the findings. The purpose of the
assignment is two-fold:

NR302 Health Assessment I

NR302 Health Assessment I

  • To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and
    developmental) affecting health and wellness.
  •  To reflect on the interactive process between self and client when conducting a health assessment.

Course Outcomes: This assignment enables the student to meet the following course outcomes:

  • CO1. Explain expected client behaviors while differentiating between normal findings, variations, and abnormalities.(PO1)
  • CO2. 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. (PO 4, 8)
  • CO3. Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual
    functioning. (PO 1)
  • CO4. Utilize effective communication when performing a health assessment. (PO 3)
  • CO6. Identify teaching/learning needs from the health history of an individual. (PO 2, 3)
  • CO7. Explore the professional responsibilities involved in conducting a comprehensive health assessment and
    providing appropriate documentation. (PO 6, 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
The Health History Worksheet can be used to help you organize the Family Medical History information you
will obtain from the Adult Participant (document link is on the Assignment page). The use of this tool is
optional. There are three parts to this assignment.
1. Health History Assessment (50 points/50%)
Using the following components of a health history assessment and your textbook for explicit details about
each category, complete a health assessment/history on an individual of your choice. The person interviewed
must be 18 years of age or older and should NOT be a family member or close friend. The purpose of this
restriction is to avoid any tendency to anticipate answers or to influence how the questions are answered. Your
goal in choosing an interviewee is to simulate the interaction between you and an individual for whom you
would provide care. It is important that you inform the person of your assignment and assure him/her that the
information obtained will be kept confidential. Please be sure to avoid the use of any identifiers in preparing
the assignment. Health History components to be included:
a) Demographics
b) Perception of Health
c) Past Medical History
d) Family Medical History
e) Review of Systems
f) Developmental Considerations
g) Cultural Considerations
h) Psychosocial Considerations
i) Collaborative Resources
2. Reflection (40 points/40%)
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 Health
History.
a) Reflect on your interaction with the interviewee holistically.

  •  Consider 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 (if needed, refer to your text for a description of therapeutic communication
    and of the interview process).

b) How did your interaction compare to what you have learned?
c) What went well?
d) What barriers to communication did you experience?

  • I. How did you overcome them?
  • II. What will you do to overcome them in the future?

e) Were there unanticipated challenges to the interview?
f) Was there information you wished you had obtained?
g) How will you alter your approach next time?
3. Style and Organization (10 Points/10%)
Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information,
and appropriate writing skills. Scoring of your work in written communication is based on proper use of
grammar, spelling and how clearly you express your thoughts and reasoning in your writing.

  •  Grammar and mechanics are free of errors.
  •  Able to verbalize thoughts and reasoning clearly
  •  Use appropriate resources and ideas to support topic

For writing assistance (APA, formatting, or grammar) visit the Citation and Writing Assistance: Writing Papers at CU
page in the online library.

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