Health History Assessment Essay

Instruction is attached.

Read carefully.

No minimum pages as long as questions and targeted topics is answered properly.

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css

REQUIRED UNIFORM ASSIGNMENT GUIDELINES

Health History Assessment Essay” class=”wp-image-733″/>

THE HEALTH HISTORY AND PHYSICAL EXAMINATION

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.

• 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

• 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

CO1: CO1. 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, 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) CO5: 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, 5) CO 7: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO 6, 7)

DUE DATE Please see the Course Calendar.

TOTAL POINTS POSSIBLE 100 points

PREPARING THE ASSIGNMENT

There are four graded parts to this assignment: (1) Obtain a health history and conduct a physical examination on an individual of your choosing (not a patient), (2) compile a health education needs assessment, (3) self-reflection, and (4) writing style and format.

Instructions for each part follow.

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css

Health History Assessment and Physical Assessment (50 points)

 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 

NR304. Please be sure to avoid the use of any identifiers in preparing the assignment. Students may seek input from the course instructor on securing an individual for this assignment. 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. 1. Subjective Data—Health History Components to Be Included

• Demographic data

• Reason for care (why they are in the facility)

• Present illness (PQRST of current illness)

• Perception of health

• Past medical history (including medications, allergies, and vaccinations and immunizations)

• Family medical history

• Review of systems

• Developmental considerations

• Cultural considerations

• Psychosocial considerations

• Presence or absence of collaborative resources (community, family, groups, and healthcare system)

***REMEMBER: Make notes of the health history findings, ensuring that you have addressed all of the

components listed here. Students are also encouraged to take notes about their experiences while

conducting the health history for reference when creating the assignment, particularly the reflection section.

2. Objective Data—Physical Exam Components to Be Included

 During the lab experiences, you will conduct a series of physical exams that includes the following systems.

 Keep notes on each part of the physical exam as you complete them to reference as you write the paper.

 Refer to the course textbook for detailed components of each system exam. Remember, assessment of the integumentary system is an integral part of the physical exam and should be included throughout each system.

 From NR302

o HEENT (head, eyes, ears, nose, and throat)

o Neck (including thyroid and lymph chains)

o Respiratory system

o Cardiovascular system

 From NR304

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css

o Neurological system

o Gastrointestinal system

o Musculoskeletal system

o peripheral vascular system

***REMEMBER: Make notes of the physical examination findings, ensuring that you have addressed all of the

components listed on the Return Demonstration Checklist. Students are also encouraged to take notes

about their experiences while conducting the physical examination for reference when creating the

assignment, particularly the reflection section.

Needs Assessment (20 points)

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. Select two peer-reviewed journal articles that provide evidence-based support for the health teaching needs you have identified.

Reflection (20 points)

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.

1. 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?

Writing Style and Format (10 points)

Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired

information, and appropriate writing skills. Scoring of your written communication is based on

proper use of grammar, spelling, and APA sixth-edition formatting, as well as how clearly your

thoughts and reasoning are expressed in writing.

Documentation of Findings or How to Write the Paper

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css

Using Microsoft Word, create a double-spaced document. The paper should be formatted according to APA sixth-edition guidelines for the title page, running head, and reference page. The use of headings is required for this paper. All portions of this assignment should be included within the paper, including the reflection.

1. Begin by writing one to two paragraphs describing the individual’s stated condition of health medications and allergies. Also, include any of the following information that may be pertinent: demographic data, perception of health, past medical history, vaccinations and immunizations, family medical history, review of systems, developmental considerations, cultural considerations, psychosocial considerations, and the presence or absence of resources from the community, family, groups, or the healthcare system.

2. Write one paragraph describing the physical assessment findings, ensuring proper terminology is used to describe any abnormal or unusual findings.

3. Write one paragraph discussing (1) the rationale for the selection of the health teaching topics and (2) how the findings in the scholarly articles (identified in the needs assessment portion of the assignment and properly cited) were used to develop the health teaching topics to promote the individual’s health and wellness status.

4. Write one paragraph discussing (1) how the interrelationships of physiological, developmental,

cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education and (2) a description of the impact of the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) on the proposed teaching.

5. Write one paragraph describing your reflection of this assignment from a holistic point of view.

Consider the following areas: Include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process. You may find your textbook helpful in providing a description of therapeutic communication and of the interview process. Be certain to address the questions listed above in the reflection instructions.

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css

Chamberlain College of Nursing NR304 Health Assessment II

DIRECTIONS AND GRADING CRITERIA

Category Points % Description

Health History and Physical Assessment

50 50 Conducts a comprehensive health history and physical exam

1. Subjective data: demographic data; reason for care; present illness; perception of health; past medical history; family medical history; review of systems; developmental considerations; cultural considerations; psychosocial considerations; and collaborative resources.

2. Objective data: HEENT; neurological system, respiratory system, cardiovascular system, neck; gastrointestinal system; musculoskeletal system; and peripheral vascular system.

Provides a written narrative that includes the following

1. One to two paragraphs describing stated condition of health, medications, and allergies. Also includes the following information: demographic data, perception of health, past medical history, vaccinations and immunizations, family medical history, review of systems, any developmental considerations, cultural considerations or psychosocial considerations, presence or absence of resources from the community, family, groups, or from the healthcare system

2. One paragraph describing: the findings of the physical examination

3. One paragraph discussing (1) the rationale for the selection of the health education topics and (2) how the findings in the scholarly articles were used in support of the health teaching topic to promote or improve the individual’s health and wellness status.

4. One paragraph discussing (1) how the interrelationships of

physiological, developmental, cultural, and psychosocial considerations influence (assist or become barriers to the effectiveness) the proposed health education and (2) provide a description of the impact of the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, family, community, and health and wellness resources) on the proposed nursing teaching.

Needs Assessment

20 20 1. Identifies two health education needs for the individual based on the health history and physical examination findings and two peer- reviewed journal articles providing evidence-based support for the identified health teaching needs

2. APA sixth-edition formatting used for in-text and reference page citations

Chamberlain College of Nursing NR304 Health Assessment II

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 5 Revised 11/05/18 EL/css

Reflection 20 20 Reflects on the interaction with the interviewee holistically. Considers the interaction in its entirety: includes the environment, the approach to the individual, time of day, and other features relevant to therapeutic communication and the interview process. The reflection should address each of the following questions.

 How did your interaction compare to what you’ve learned and expected?

 What enablers or barriers to communication did you experience? How did you overcome the barriers?

 Were there any unanticipated challenges to conducting the interview or performing the physical examination? What went well?

 Was there information you wished you had but did not?

 How will you alter your approach the next time?

Writing Style and Format

10 10 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 writing. Proper use of APA sixth-edition style and format throughout this paper is required.

Total 100 100

NR304 Health Assessment II Chamberlain College of Nursing

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4

GRADING RUBRIC

Assignment Criteria

Outstanding or Highest Level of Performance

A (92–100%)

Very Good or High Level of Performance

B (84–91%)

Competent or Satisfactory Level of Performance

C (76–83%)

Poor, Failing or Unsatisfactory Level of Performance

F (0–75%)

Health History and Physical Examination (50 points)

Thoroughly presents a health history narrative that includes a detailed description of all the following components

 Demographic data

 Reason for care

 Present illness

 Perception of health

 Past medical history

 Family medical history

 Review of systems  Developmental

considerations

 Cultural considerations

 Psychosocial considerations

 Collaborative resources

Thoroughly presents a physical exam narrative that includes a detailed description of all the following components HEENT  Neurological system  Neck

 Respiratory system

One of the key elements of the health history narrative is not presented or lacks sufficient detail.

 Demographic data

 Reason for care

 Present illness

 Perception of health

 Past medical history

 Family medical history

 Review of systems  Developmental

considerations

 Cultural considerations

 Psychosocial considerations

 Collaborative resources

One of the key elements of the physical exam is not presented or lacks sufficient detail. HEENT • Neurological system • Neck • Respiratory system • Cardiovascular system • Gastrointestinal system

Two of the key elements of the health history narrative are not presented or lack sufficient detail.

 Demographic data

 Reason for care

 Present illness

 Perception of health

 Past medical history

 Family medical history

 Review of systems  Developmental

considerations

 Cultural considerations

 Psychosocial considerations

 Collaborative resources

Two of the key elements of the physical exam are not presented or lacks sufficient detail. • HEENT • Neurological system • Neck • Respiratory system • Cardiovascular system • Gastrointestinal system • Musculoskeletal system

Three or more of the key elements of the health history narrative are not presented or lack sufficient detail.

 Demographic data

 Reason for care

 Present illness

 Perception of health

 Past medical history

 Family medical history

 Review of systems  Developmental

considerations

 Cultural considerations

 Psychosocial considerations

 Collaborative resources

Three or more of the key elements of the physical exam are not presented or lack sufficient detail.

 HEENT

 Neurological system

 Neck

 Respiratory system

 Cardiovascular system

 Gastrointestinal system

NR304 Health Assessment II Chamberlain College of Nursing

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 5

 Cardiovascular system

 Gastrointestinal system

 Musculoskeletal system

 Peripheral vascular system

 Integumentary system integrated in exam of all systems where appropriate

Information is presented in a clear, organized, and professional manner.

46-50 points

• Musculoskeletal system • Peripheral vascular system • Integumentary system

integrated in exam of all systems where appropriate

Information is presented in a clear, organized, and professional manner.

42-45 points

• Peripheral vascular system • Integumentary system

integrated in exam of all systems where appropriate

Information is not presented in a clear, organized, and professional manner.

38-41 points

 Musculoskeletal system

 Peripheral vascular system

 Integumentary system integrated in exam of all systems where appropriate

Information is not presented in a clear, organized, and professional manner.

0–37 points

Needs Assessment (20 Points)

Accurately identifies two health education needs for this individual and provides at least three factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.

References two peer-reviewed journal articles that provide evidence-based support for the health teaching; APA format (most current edition) used to list the sources.

19-20 points

Accurately identifies a health education need for this individual and provides at least two factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.

References two peer-reviewed journal articles that provide evidence-based support for the health teaching but does not use appropriate APA format (most current edition) to list the sources.

17-18 points

Accurately identifies a health education need for this individual and provides at least two factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.

References one peer-reviewed journal articles that provides evidence-based support for the health teaching but does not use appropriate APA format (most current edition) to list the sources.

16 points

Accurately identifies a health education need for this individual and poorly or minimally applies one or more factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.

No references are submitted or, if they are used, they have three or more types of errors in APA format (most current edition) to list the sources.

0–15 points

Reflection

(20 Points)

Thoughtfully appraises the individual holistically. Reflection

Thoughtfully appraises the individual holistically. One of the following questions is not

Broadly appraises the individual. Two of the following questions

Broadly appraises the individual. Three or more of the following

NR304 Health Assessment II Chamberlain College of Nursing

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 6

includes a detailed response to all the following questions.

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter your approach the next time?

Key and relevant information is presented in sufficient detail and is clear and organized.

19-20 points

presented or lacks sufficient detail.

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter your approach the next time?

Key and relevant information is presented in sufficient detail and is clear and organized.

17-18 points

are not presented or lack sufficient detail.

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter your approach the next time?

Key and relevant information is presented in insufficient detail but is clear and organized. 8 Points

questions are not presented or lack sufficient detail.

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter your approach the next time?

Key and relevant information is presented in insufficient detail and is not clear or organized. 0–7 points

Writing Style and Format (10 points)

Student presents information using clear and logical language. Grammar, spelling, and punctuation are free of errors. APA sixth edition was used to guide the style and format of this paper. 10 points

Student presents information using clear and logical language. Grammar, spelling, and punctuation have two or fewer types of errors, or there is no more than one error in APA sixth-edition formatting. 9 points

Student presents information using clear and logical language. Grammar, spelling, and punctuation have three types of errors, or there are no more than two errors in APA sixth-edition formatting.

8 points

Information is unclear and difficult to follow. Grammar, spelling, and punctuation have three or more types of errors, or there are more than three errors in APA sixth-edition formatting.

0–7 points

Total Points Possible = 100 points

8/7/2019 Grades for Hannah Gabon: Health Assessment II-Stigler

https://chamberlain.instructure.com/courses/45424/grades 2/3

Close Rubric

NAME DUE SCORE OUT OF

Week 7: RUA: Health History and Physical Assessment Supplemental Assignments

Aug 11 by 11:59am 100

Assessment by Christa Stigler

Health History and Physical Assessment

CRITERIA RATINGS PTS

Health History

and Physical

Examination

Comments Hannah, You did not address the client’s perception of health. The review of systems did not include them all and was very vague (what were the results? What did the patient tell you?). Developmental, cultural, psychosocial, and collaborative resources were not addressed.

37 / 50 pts

Needs

Assessment

Comments Hannah, Although you discussed some teaching points for patients in general, you did not address speci�c needs for this patient nor how he could incorporate them into his life. You also only had one journal article and the rubric required 2.

5 / 20 pts

Re�ection 15 / 20 pts

Writing Style

and Format

Comments Hannah, You had several APA formatting issues and issues with grammar. You can use grammarly in the library to help with this and owl@purdue for APA formatting assistance. You also had several areas of the rubric either not addressed or not addressed fully. Please see embedded comments throughout paper for more detailed feedback.

5 / 10 pts

Total Points: 62

50 to >45 pts

Outstanding or Highest Level of

Performance

Thoroughly presents a health history

narrative that includes a detailed description

of all the following components •

Demographic data • Reason for care •

Present illness • Perception of health • Past

medical history • Family medical history •

Review of systems • Developmental

considerations • Cultural considerations •

Psychosocial considerations • Collaborative

resources Thoroughly presents a physical

exam narrative that includes a detailed

description of all the following components

HEENT • Neurological system • Neck •

Respiratory system • Cardiovascular system

• Gastrointestinal system • Musculoskeletal

system • Peripheral vascular system •

Integumentary system integrated in exam of

all systems where appropriate Information is

presented in a clear, organized, and

professional manner.

45 to >41 pts

Very Good or High Level of Performance

One of the key elements of the health history

narrative is not presented or lacks suf�cient

detail. • Demographic data • Reason for care

• Present illness • Perception of health • Past

medical history • Family medical history •

Review of systems • Developmental

considerations • Cultural considerations •

Psychosocial considerations • Collaborative

resources One of the key elements of the

physical exam is not presented or lacks

suf�cient detail. HEENT • Neurological

system • Neck • Respiratory system •

Cardiovascular system • Gastrointestinal

system • Musculoskeletal system •

Peripheral vascular system • Integumentary

system integrated in exam of all systems

where appropriate Information is presented

in a clear, organized, and professional manner.

41 to >37 pts

Competent or Satisfactory Level of

Performance

Two of the key elements of the health history

narrative are not presented or lack suf�cient

detail. • Demographic data • Reason for care

• Present illness • Perception of health • Past

medical history • Family medical history •

Review of systems • Developmental

considerations • Cultural considerations •

Psychosocial considerations • Collaborative

resources Two of the key elements of the

physical exam are not presented or lacks

suf�cient detail. • HEENT • Neurological

system • Neck • Respiratory system •

Cardiovascular system • Gastrointestinal

system • Musculoskeletal system •

Peripheral vascular system • Integumentary

system integrated in exam of all systems

where appropriate Information is not

presented in a clear, organized, and

professional manner.

37 to >0 pts

Poor, Failing or Unsatisfactory Level of

Performance

Three or more of the key elements of the

health history narrative are not presented or

lack suf�cient detail. • Demographic data •

Reason for care • Present illness • Perception

of health • Past medical history • Family

medical history • Review of systems •

Developmental considerations • Cultural

considerations • Psychosocial considerations

• Collaborative resources Three or more of

the key elements of the physical exam are not

presented or lack suf�cient detail. • HEENT •

Neurological system • Neck • Respiratory

system • Cardiovascular system •

Gastrointestinal system • Musculoskeletal

system • Peripheral vascular system •

Integumentary system integrated in exam of

all systems where appropriate Information is

not presented in a clear, organized, and

professional manner.

20 to >18 pts

Outstanding or Highest Level of

Performance

Accurately identi�es two health education

needs for this individual and provides at least

three factors that may, positively or

negatively, in�uence the person’s ability to

incorporate the health teaching to improve

his or her well-being. References two peer-

reviewed journal articles that provide

evidence-based support for the health

teaching; APA format (most current edition)

used to list the sources.

18 to >16 pts

Very Good or High Level of Performance

Accurately identi�es a health education need

for this individual and provides at least two

factors that may, positively or negatively,

in�uence the person’s ability to incorporate

the health teaching to improve his or her well-

being. References two peer-reviewed journal

articles that provide evidence-based support

for the health teaching but does not use

appropriate APA format (most current

edition) to list the sources.

16 to >15 pts

Competent or Satisfactory Level of

Performance

Accurately identi�es a health education need

for this individual and provides at least two

factors that may, positively or negatively,

in�uence the person’s ability to incorporate

the health teaching to improve his or her well-

being. References one peer-reviewed journal

articles that provides evidence-based support

for the health teaching but does not use

appropriate APA format (most current

edition) to list the sources.

15 to >0 pts

Poor, Failing or Unsatisfactory Level of

Performance

Accurately identi�es a health education need

for this individual and poorly or minimally

applies one or more factors that may,

positively or negatively, in�uence the person’s

ability to incorporate the health teaching to

improve his or her well-being. No references

are submitted or, if they are used, they have

three or more types of errors in APA format

(most current edition) to list the sources.

20 to >18 pts

Outstanding or Highest Level of

Performance

Thoughtfully appraises the individual

holistically. Re�ection includes a detailed

response to all the following questions. • How

did your interaction compare to what you’ve

learned? • What went well? • What barriers

to communication did you experience? • How

did you overcome them? • Were there

unanticipated challenges to the interview? •

Was there information you wished you’d

obtained? • How will you alter your approach

the next time? Key and relevant information is

presented in suf�cient detail and is clear and

organized.

18 to >8 pts

Very Good or High Level of Performance

Thoughtfully appraises the individual

holistically. One of the following questions is

not presented or lacks suf�cient detail. • How

did your interaction compare to what you’ve

learned? • What went well? • What barriers

to communication did you experience? • How

did you overcome them? • Were there

unanticipated challenges to the interview? •

Was there information you wished you’d

obtained? • How will you alter your approach

the next time? Key and relevant information is

presented in suf�cient detail and is clear and

organized.

8 to >7 pts

Competent or Satisfactory Level of

Performance

Broadly appraises the individual. Two of the

following questions are not presented or lack

suf�cient detail. • How did your interaction

compare to what you’ve learned? • What

went well? • What barriers to communication

did you experience? • How did you overcome

them? • Were there unanticipated challenges

to the interview? • Was there information

you wished you’d obtained? • How will you

alter your approach the next time? Key and

relevant information is presented in

insuf�cient detail but is clear and organized.

7 to >0 pts

Poor, Failing or Unsatisfactory Level of

Performance

Broadly appraises the individual. Three or

more of the following questions are not

presented or lack suf�cient detail. • How did

your interaction compare to what you’ve

learned? • What went well? • What barriers

to communication did you experience? • How

did you overcome them? • Were there

unanticipated challenges to the interview? •

Was there information you wished you’d

obtained? • How will you alter your approach

the next time? Key and relevant information is

presented in insuf�cient detail and is not clear

or organized.

10 to >9 pts

Outstanding or Highest Level of

Performance

Student presents information using clear and

logical language. Grammar, spelling, and

punctuation are free of errors. APA sixth

edition was used to guide the style and format

of this paper.

9 to >8 pts

Very Good or High Level of Performance

Student presents information using clear and

logical language. Grammar, spelling, and

punctuation have two or fewer types of

errors, or there is no more than one error in

APA sixth-edition formatting.

8 pts

Competent or Satisfactory Level of

Performance

Student presents information using clear and

logical language. Grammar, spelling, and

punctuation have three types of errors, or

there are no more than two errors in APA

sixth-edition formatting.

8 to >0 pts

Poor, Failing or Unsatisfactory Level of

Performance

Information is unclear and dif�cult to follow.

Grammar, spelling, and punctuation have

three or more types of errors, or there are

more than three errors in APA sixth-edition

formatting.

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https://chamberlain.instructure.com/courses/45424/assignments/1496449/submissions/89464https://chamberlain.instructure.com/courses/45424/assignments/1496449/submissions/89464/originality_report/attachment_5071725Hannah GabonHannah GabonHannah GabonHannah Gabon

Running head: HEALTH HISTORY AND PHYSICAL ASSESSMENT 1

Health History and Physical Assessment

Hannah Gabon

Chamberlain College of Nursing

NR304 Health Assessment II

Professor Christa Stigler

August 2019Hannah GabonHannah GabonHannah Gabon

Health History Assessment and Physical Assessment 2

Health History Assessment and Physical Assessment

I conducted a health assessment on a 70 year’s old male patient from California who was

suffering from hypertension. The patient is currently taking diuretics medication which cause

increase urination. The medication also causes his sodium and fluids levels to drop thus lowering

patient’s blood pressure so it’s imperative to balance and monitor vital sign. The patient stated

that he was moderately satisfied with the care received in the facility. The patient is a smoker and

stated his concern of experiencing vision issues and heart failure, which prompted immediate

care for this patient.

Before being admitted to the hospital, patient stated that he was experiencing chest pain

which was not ending nor was it increasing in exertion. He did not experience nausea, vomiting,

dizziness or unconsciousness. He took some pain killers with no relief but managed to sleep in

the morning. After beginning his daily activities, the pain increased and was then rushed to the

hospital. He underwent some test that clarified that he was suffering from hypertension. When I

reviewed patient past medical records, it showed that he has condition at early age and minor

surgery. I reviewed the patient’s cardiovascular, eyes, nose, throat, respiratory system, and his

immune system. Patient immunization was also put into consideration when I reviewed his past

medical record as this will be helpful planning for his care.

Thirty years ago, the patient developed a diffuse rash after he was injected with penicillin

which he was allergic to, but it was not known. Some of his past health operations includes:

chest pains in 1990 and minor surgery on his left arm. He has a medical case of pneumonia at an

early age, which did not take long to heal. The patient was raised by his stepmother since his

mother passed away 72 years ago from heart failure. His father passed on 68 years ago after

committing suicide in his house. His wife died 10 years ago after struggling with tuberculosis forHannah Gabon98440000000099648what condition?

Health History Assessment and Physical Assessment 3

a long period of time. He has six children; two are deceased after both suffered from

hypertension. He has 20 grandchildren and 10 great-grandchildren. His family have history of

hypertension but no known history of tuberculosis.

The patient’s physical assessment findings were that he had an elevated blood pressure of

125/80 which shows that it was high, but it is controllable. I also found that he had a unique heart

sound which was as a result of an enlarged heart. The patient had a swollen neck vein which was

probably caused by heart failure. He also had some abnormalities in the blood vessels behind the

eyes. He has no clinical cardiovascular disease or signs of hypertension-related target- organ

damage. The patient had narrowed kidney arteries and endocrine disorders. The patient had no

respiratory problems, but his lungs sounded as if it was congested. His peripheral pulses were

present and strong, and his thorax was under the normal shape.

Through health teaching topics, students can acquire knowledge, skills and positive

attitude about health. From these teaching, students can learn about physical, mental emotional

and mental health. This enables students to enhance and maintain their health in preventing

diseases and minimize risky habits (Don, 2000). Through this teaching, student acquire positive

changes and behaviors that reduce the risk of the student being around alcohol, tobacco, and

other drugs. Through this teaching, the community becomes aware of how to prevent chronic

diseases as well as how to maintain healthy nutrition and prevent obesity (Vadurro, 2018).

Through the finding in the scholarly articles, there has been great awareness about chronic

diseases and how they can be prevented and managed by integrating such as nutrition and how to

deal with stress. The findings also advance the understanding of how the mind and body

strategies impact health and well-being. The findings mainly focus on the treatment of diseases,Hannah Gabon98440000000099648under??????????Hannah Gabon98440000000099648How do you know?Hannah Gabon98440000000099648they were congested.Hannah Gabon98440000000099648nurse’s are not qualified to determine this.Hannah Gabon98440000000099648How would you know this?

Health History Assessment and Physical Assessment 4

this has helped in finding treatment for diseases and the productiveness of pharmacologic

strategies in treating and controlling the illnesses (Green LW. Et al. 1980)

The interrelationship of psychological developmental, cultural and psychosocial

consideration impacts a person’s experiences and definition of health and illnesses. This

relationship guides the day to day lifestyle of people. It determines if people in given community

access to health care and their responses to disease pain and disabilities. Through the integration

of individual strength and collaborative resources, the proposed health teaching will be well

appreciated in the community since through these strengths they will improve the population-

level health outcome by supporting the proposed health teaching which may lead to a sustainable

environmental transition in different parts of the community which are associated with health.

The patient was not willing to share the information with me as he considered it as a

distraction. To comfort patient, I began by explaining to him the importance of the interview. I

explained to him the information was required for learning purpose which helped in convincing

him that the interview was not aimed at interfering with his privacy since the information will

not be shared by any third party. I explained to him the benefits of speaking about his health

conditions and with the information shared, it will be easier to come up with a better medical

plan that will help a medical professional care for his needs. I explained to him that if he shared

his health information, I will be able to explain to him the living habits that he was expected to

adapt based on his condition. When conducting my next physical examination, I will ensure that

I implement the four techniques which involves inspections, palpation, percussion, and

auscultation.Hannah Gabon98440000000099648This is not correctly formatted.Hannah Gabon98440000000099648What went well? What information had you wished you had obtained.Hannah GabonThis section is very vague. I am not sure if his unwillingness to share was a barrier but if so how did you overcome it to get the information you needed?Hannah GabonDid he consent to the assessment? I am unclear on this.

Health History Assessment and Physical Assessment 5

References:

Don Nutbeam. (2000, September) Health literacy as a public health goal: a challenge for

contemporary health education and communication strategies into the 21st

century, Health Promotion International, 15(3), Pp. 259–267. Retrieved from

https://doi.org/10.1093/heapro/15.3.259

Vadurro Marcy. (2018, February 8). The Importance of Health Education. Retrieved from

https://www.snhu.edu/about-us/newsroom/2018/02/importance-of-health-education

Green LW. Et al. (1980). Health education planning: a diagnostic approach. Retrieved from

https://www.popline.org/node/499039https://doi.org/10.1093/heapro/15.3.259https://www.snhu.edu/about-us/newsroom/2018/02/importance-of-health-educationhttps://www.popline.org/node/499039