Chat with us, powered by LiveChat In order to demonstrate your understanding of the content explored in this course, you will write a history and physical paper. | WriteDen

In order to demonstrate your understanding of the content explored in this course, you will write a history and physical paper.

NU304 Health Assessment in Nursing

Week 8 Assignment  

History and Physical Paper

Instructions

In order to demonstrate your understanding of the content explored in this course, you will write a history and physical paper. Listed below are the specific topics that should be included in your paper. Please review the sample history and physical paper and guide for charting history and physical objective data prior to beginning your assignment.

 

Reason for Contact: Well Visit

 

Biographical Data: Name, age, address, next of kin, sex, ethnic group, religious affiliation, language

 

Social History/Client Profile

 

Occupation/School/Past travel

 

Past and present support systems

 

Adjustment to present living situation (safety issues: smoke detectors, CO detectors, alarm system, safe neighborhood, etc.)

 

Family relationships

 

Relationship to staff (if institutionalized)

 

Describe present living situation (24 hour daily routine)

 

Daily habits, diet (24 hour food recall), elimination, use of tobacco, ETOH, recreational drugs (if applicable), exercise, hobbies, sleep patterns

 

Current Health Status: Describe present health status taking into consideration:

 

Functional capabilities

 

ADL assessment

 

Mental functioning

 

present chronic physical diseases being monitored (if applicable)

 

Medications (RX, OTC, herbal)

 

Allergies

 

Past Health History

 

Past medical illnesses

 

Past surgical procedures/hospitalizations

 

Allergies

 

Immunizations

 

Family History: Immediate family (grandparents, parents, siblings, children) describe:

 

Age

 

Relationship to family

 

Health status of each

 

Note familial diseases/Genogram

 

Review of Systems

 

General: Body weight, loss or gain, time interval

 

Skin: Texture of skin, rashes, discolorations, itching, dryness or moisture, sweating, condition of hair and nails

 

Hematopoietic system: Anemia, transfusions and reactions (include dates), spontaneous bleeding or excessive bleeding after tooth extractions, tonsillectomy or minor surgery, enlarged, tender nodes

 

Head: Headache, vertigo, trauma

 

Eyes: Vision, lacrimation, photophobia, itching, pain

 

Ears: Deafness, pain, discharge, vertigo, tinnitus

 

Nose and sinuses: Nasal discharge, obstruction, frequent colds, allergies, trauma, sense of smell

 

Mouth and throat: Pain, bleeding gums, soreness or mouth and tongue, dysphagia, changes in voice, dental hygiene

 

Neck: Pain, swelling and limitation of motion

 

Breasts: Lump, pain, discharge

 

Cardiorespiratory system: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, cough, sputum, hemoptysis, pain, wheezing, palpitations syncope, cyanosis, hypertension, hoarseness, stridor, intermittent claudication

 

Gastrointestinal system: Appetite, dysphagia, pyrosis, indigestion, food intolerances, nausea, hematemesis, flatulence, jaundice, abdominal pain or discomfort, change in bowel habits, diarrhea, constipation, melena, character of stools, hemorrhoids

 

Genitourinary system: frequency, nocturia, urgency, hesistancy, oliguria, hematuria, pyuria, renal colic, dysuria, dark urine, edema, dribbling or incontinence, venereal disease (Male sexual history should be included here – STE)

 

Menstrual and obstetric: Date of last period, interval, duration, amount, age of menarche, age of menopause, dysmenorrhea, metrorrhagia, vaginal discharge, dyspareunia, number of pregnancies, deliveries and any significant complications (sexual history should be included here – SBE, mammogram)

 

Nervous system: Convulsions, vertigo, sensory disturbances. pain, paresthesia, paresis, any unusual thoughts, delusions, hallucinations or memory loss, mental health history

 

Musculoskeletal system: muscular pain, joint pain, swelling or deformity, back trouble

 

Endocrine system: Excessive thirst, urination or food intake, intolerance to heat or cold, changes in hair pattern, development of unusual patterns of obesity, tremor of hands, etc.

 

Ask client/patient to describe him/herself in one or two sentences

 

Objective Information: Chart physical exam findings (vital signs, general, head-to-toe exam)

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