NU231LL University of Nairobi Health History Physical Assessment Worksheet

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crgreamvbajru

Health Medical

NU231LL

University of Nairobi

Description

In this second submission of your Course Project, you will be completing a health history, physical assessment of your client and determining their nursing diagnoses. This written assignment should include the following:

Health Assessment, Health History, and Nursing Diagnosis

  1. A brief medical/health history
  2. Summary of laboratory diagnostic results related to the illness/condition and what they mean
  3. Summary of a head to toe physical assessment
  4. Your nursing diagnosis

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Explanation & Answer

Answer posted please confirm.Kindly go through the work and let me know if you need anything rectified or if a certain requirement has not been met

Rasmussen College
NU231LL Professional Nursing
Clinical Worksheet Revds. 10/8/14

Weekly Concept Focus
1)
2)
3)
4)
5)
6)
7)

Mobility or Safety
Elimination
Oxygenation: Gas Exchange
Thermoregulation or fluid and electrolytes
Inflammation/infection
Tissue Integrity
Pain

Date:
Clinical Site
Instructor:
Overweight/underwei
ght:
Marital
Status:
Cultural
Background:
Diet/Nutriti
on:
Treatment
s:
Interdisciplinary
Cares
(OT/PT/RT):
Dressings/Wounds:
(type & location)
Oxygen:
(delivery method &
amount)

Student
name:

Clinical
Site/Unit:
Clinical Site
Mentor:
Allergie
s:
Religion:
Primary
Language:

Code
status:
Activity
:
IV/Tubes/Ostomie
s:

Dialysis
:

1

Rasmussen College
NU231LL Professional Nursing
Clinical Worksheet Revds. 10/8/14

Measles

Patient reports experiencing high
sensitivity to light, dry hacking
cough, general body aches, runny

Admitting Medical Diagnosis(s):
nose, and watery eyes. The patient
reported the symptoms for about
eleven days (Nordqvist, 2017).
Hearing problems

Patient’s reports from other clinics

Primary (if different than
show existence of hearing problems
Admitting)
for a period of five years.

Malaria
Secondary
(Do not include History Of):

2

3 nursing interventions:
1. will encourage the
patient to go to outdoor
activities
2. will tell the patient to
avoid being alone
3. will consoul the
client that the disease is
normal

Evaluation:
This will ensure
client stays
positive

Rasmussen College
NU231LL Professional Nursing
Clinical Worksheet Revds. 10/8/14

Diagnosis: risk for facing
depression issues

Evaluation: The
strategy will
help the client
stay free from
other infections

3 nursing interventions:
1. will educate client on
the importance of
staying fully covered
2. will tell the client to
apply his medication
frequently
3. will tell the client to
maintain hygene

Outcome: disease
affects the ear and
its organs

Outcome: Isolation

Diagnosis: risk for losing
hearing abilities

Outcome: through
the skin open
wounds

Evaluation:
This will ensure
client’s ears are
active

Evaluation:
This will aid
with complete
reduction of the
abdominal
pains

Nursing Care Plan
Henry Cork

Diagnosis: risk for getting
other diseases due to open
wounds

3 nursing interventions:
1. will inform the client
to always apply
medication to the ears
2. will inform the client
to ensure his ears are
active
3. will inform to
participate in social
activitie

Diagnosis: risk for getting
abdominal pains

3 nursing interventions:
1. will advise client to
stay active
2. will inform the client
to take a lot of water
3. will educate client to
eat well

Outcome: Vomiting
and diarrhea
3

Rasmussen College
NU231LL Pr...

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