Health Medical
NSG 330 Stratford University CH28 Biographical Data & Health Assessment Paper

NSG 330

Stratford University


Question Description

I don’t understand this Nursing question and need help to study.

This should include the cultural assessment, genogram, and health history. Appropriate headings required in each area. References required for unoriginal work or if using a genogram generator.

Student may use pages 29 to 36 in Jarvis Student Laboratory Manual as reference guide

Student may also use end of Chapter 28 in Jarvis textbook as guide and samples of health histories (Pg 778-782)

Please see attachment for Instructions/Rubric, sample and Book pages.

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NSG330 Health Assessment and Diagnostic Reasoning Grading Criteria for Partner Complete Health History Paper Student Name:__________________________________________ Date:____________________ Format Possible Points Paper is typed and turned in on time, 5 with coversheet Words in history are selected by student and not copied directly from a textbook. Student’s Score 5 Content Biographical Data, Source and Reliability of Information, Reason for Seeking Care are complete. Possible Points 5 History of Present Illness is written in paragraph form. Present health included. 10 Past Medical History, Past Surgeries and Hospitalizations, Medications and Allergies listed, with dates. 10 Social History (Alcohol, tobacco, drugs, marital , including health status. 10 Construction of Genogram 10 Review of Systems – discuss each system and use abbreviated format, not complete sentences Functional Assessment (Including Activities of Daily Living) Total 30 Student’s Score 15 100 points Actual points = Student may use pages 29 to 36 in Jarvis Student Laboratory Manual as reference guide Student may also use end of Chapter 28 in Jarvis textbook as guide and samples of health histories (Pg 778782) NSG330 History & Physical Format Write this up with these headings. SUBJECTIVE (History) Identification name, address, tel.#, DOB, informant, referring provider CC (chief complaint) list of symptoms & duration. reason for seeking care HPI (history of present illness) – PQRST Provocative/palliative - recipitating/relieving Quality/quantity - character Region - location/radiation Severity - constant/intermittent Timing - onset/frequency/duration PMH (past medical /surgical history) general health, weight loss, hepatitis, rheumatic fever, mono, flu, arthritis, Ca, gout, asthma/COPD, pneumonia, thyroid dx, blood dyscrasias, ASCVD, HTN, UTIs, DM, seizures, operations, injuries, PUD/GERD, hospitalizations, psych hx Allergies Meds (Rx & OTC) SH (social history) birthplace, residence, education, occupation, marital status, ETOH, smoking, drugs, etc., sexual activity - MEN, WOMEN or BOTH CAGE Review Ever Feel Need to CUT DOWN Ever Felt ANNOYED by criticism of drinking Ever Had GUILTY Feelings Ever Taken Morning EYE OPENER FH (family history) age & cause of death of relatives' family diseases (CAD, CA, DM, psych) SUBJECTIVE (Review of Systems) skin, hair, nails - lesions, rashes, pruritis, changes in moles; change in distribution; lymph nodes - enlargement, pain bones , joints muscles - fractures, pain, stiffness, weakness, atrophy blood - anemia, bruising head - H/A, trauma, vertigo, syncope, seizures, memory eyes- visual loss, diplopia, trauma, inflammation glasses ears - deafness, tinnitis, discharge, pain nose discharge, obstruction, epistaxis mouth - sores, gingival bleeding, teeth, abn. taste, jaw pain throat - ST, hoarseness, voice changes, URI neck - swelling/stiffness, adenopathy, goiter, breasts - lumps, pain, nipple discharge, last mammogram endocrine - polyphagia/dipsia/uria, dec. energy/fatigue respiratory - dyspnea, orthopnea, wheezing, cough, sputum, hemoptysis, pain, pleurisy, night sweats, TB, #pillows, pneumonia, asthma CV (cardiovascular) - CP, palpitations, claudication peripheral edema, ascites, cold feet, phlebitis, cyanosis GI - appetite/wgt change, dysphagia, N/V, hematemesis, BRBPR, melena, abd, pain/colic, icterus, diarrhea, constipation, change in bowels, tenesmus, hemorrhoids ,rectal pain, hernia GU - polyuria, oliguria, dysuria/strangury, hematuria, pyuria, incontinence, nocturia, pain passage of stones, UTI, pyelo & STD hx MS - arthralgia, arthritis, myalgia, joint stiffness/swelling/ heat/pain, podagra/gout nervous - smell, chewing, visual, facial weakness, hearing, balance, speech & swallowing, taste, motor - weakness, paralysis, atrophy, seizures, incoordination sensory - pain, paresthesias, anesthesia autonomic - incontinence, sweating, erythema, cyanosis, pallor, temp sensitivity mental status - relations w family, lability of mood, hallucinations, delusions, depression, somnolence, insomnia OBJECTIVE (Physical Exam - sample recordings) vital signs & general appearance: age, sex, well developed/nourished, appears stated age, NAD head - normocephalic, no masses /lesions, cicatrices, malar flushing eyes - visual fields intact (cut)by confrontation, PERRLA , conjunctiva clear, sclera white, anicteric, (1-2 beat nystagmus on lateral gaze.) EOMI, no ptosis; fundi: red reflex present (B). discs flat w sharp margins, vessels present w/o crossing defects, retinal hemorrhages ears - TM's non-injected(erythematous, bulging), good light reflex, no protrusion or retraction; Weber midline, Rinne ac>bc, Whisper test 3:3 nose - nares patent, no deformity, septal deviation or perforation throat - pharynx non-injected, palate rises symmetrically, gag present, mouth - buccal mucosa, moist and intact, tonsils present, dentition intact, caries, tongue midline w/o fasciculations neck, axilla & breasts - no LAD (lymphadenopathy), masses, or thyromegaly/focal lump, carotid pulses 2+ & = (B), no bruits, supple full ROM trachea midline, breasts symmetric, no retraction, lesions, masses or tenderness back, thorax & lungs - chest expansion symmetric, CTA (clear to auscultation), eupnea, no adventitious sounds (rales, crackles, wheezes) CV (cardiovascular) - RRR no m/r/g (systolic ejection murmur, rubs, gallops) abdomen - soft non-tender w/o masses, tympany to percussion in all 4 quads, BS present (hyper/hypoactive, absent); no HSM (hepatosplenomegaly), no bruits extremities - extremity size symmetric w/o swelling/atrophy, temp warm (B). All pulses present, 2+ &= (B), no LAD, skin - pink-tan color, good turgor w/o lesions, redness, cyanosis, edema or cicatrices; nails - no clubbing or deformities w good cap refill musculoskeletal - gait normal, able to tandem walk, no Rhomberg's sign; joints and muscles symmetric, no swelling, masses, deformity or tenderness to palpation; no heat or swelling of joints; full ROM; muscle strength 5/5- able to Amitin flexion against resistance & w/o tenderness muscle grading – evaluate D (deltoid), T (triceps), B (biceps), WF (wrist flexion), WE (wrist extension), Quad (quadriceps), PF (plantar flexion) DF (dorsiflexion) scoring 0-5 out of 5 according to following scale: 5 NormalComplete ROM against gravity with full resistance 4 Good Complete ROM against gravity with some resist 3 FairComplete ROM against gravity 2 Poor Complete ROM with gravity eliminated 1 TraceEvidence of slight contractility. No joint motion 0 Zero No evidence of contractility genitalia/rectum - no lesions, inflammation or discharge from penis, rectum: no fissure, hemorrhoids, fistula or lesions in perianal area; sphincter tone good; prostate not enlarged, no masses, nodules or tenderness. Stool brown, guaiac neg. pelvic - no vaginal/cervical lesions, uterus size & position; no adnexal tenderness nervous - (LOC, DTR's, MMS) - CN II-XII grossly intact, alert oriented, cooperative sensory - pinprick, light touch & vibration intact; proprioception tested (unable to differentiate sharp/dull mid-calf motor - no atrophy, weakness, tremors or clonus; RAM (rapid, alt. movement) finger-tonose/heel-to-shin intact; Rhomberg negative DTR's - all 2+ & = (B); Babinski absent toes upgoing, downgoing or equivocal (inconclusive); plantar response in extensor on (L); Naming & repetition intact; memory 3:3; (B) Pronator drift - (R)>(L); gaze preference; neglect; extinguishing sensory (light touch to ea. ext then to both simultaneously): extinguishes (L or R) side to direct sen. stim. reflex grading – evaluate biceps (C5, C6); triceps (C6, C7, C8); brachioradialis (C5, C6); patellar (L2, L3, L4); Achilles’ (S1, S2); plantar/Babinski (L4, L5, S1, S2) based on following scale: 4+ very brisk/hyperactive - clonus 3+ more brisk than average 2+ average/normal 1+ low normal/diminished 0 no response or equivocal Cranial Nerve Evaluation (using specific tests) CN I (Olfactory) - smell mint leaves/tobacco CN II (Optic) - visual acuity & funduscopic CN III (Oculomotor) - pupillary reaction CN IV (Trochlear) - pupillary reaction CN V (Trigeminal) - clench teeth, open jaw, lip/chin test for light touch CN VI (Abducens) - EOM CN VII (Facial) - raise eyebrow/frown/show teeth/smile/puff cheek CN VIII (Acoustic) - whisper test; Weber/Rinne tests CN IX (Glossopharyngeal) - hoarseness, tongue movement CN X (Vagus) - saying "ah," & note palate and uvula move upward CN XI (Spinal Accessory) - shrug shoulders CN XII (Hypoglossal) - inspect tongue for atrophy/fasciculations ...
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Final Answer


Health Assessment – Outline

Role of individual health and check ups
Present health status
A. Place of birth
B. Preexisting conditions
C. Behavior during interview


Medication reconciliation
A. Nifedipine side effects
B. Metoprolol side effects


Past medical history and surgeries
A. Hypertension
B. Complications during childbirth
C. Blood pressure genetics history


Social history
A. No consumption of alcohol


A. Generational inheritance of blood pressure


Review of systems
A. General overall health – hypertension and its side effects
B. Skin nails and hair – no issue
C. HEENT- No issue
D. Respiratory system-side effects of drugs
E. Cardiovascular disease – none reported
F. Urinary system – no incidences of polyuria, nocturia and dysuria
G. Muscoloskeletal system – back pains

H. Neurologic system- no pains
I. Endocrine system- none reported
J. Hematologic system – none reported
K. Endocrine system – none reported

Functional system
A. Support from family and friends
B. Therapy sessions





Health Assessment


Health Assessment

Determining the health history of an individual is essential as it provides
comprehensive information about any underlying illness present in an individual which could
be transmitted to future generations. A complete health history also provides information on
health areas that require significant improvement. A complete health check-up focuses on
both an individual’s lifestyle habits to religious beliefs associated with managing a specific
disease condition. Therefore, it is essential that healthcare providers who assess the patient
are culturally competent and understand the role of an individual’s culture in disease
predisposition. Data should also be collected from family members to determine if the disease
has a genetic link. In such cases, a genogram becomes important in showing how specific
genetic disease are transmitted across generations and the likelihood of future generations
being diagnosed with the same disease. Interviews are considered as the most effective
approach in assessing the condition of a given patient. Therefore, it is essential that the
healthcare provider makes the other party comfortable before collecting any health
information. The information provided to the healthcare provider should remain confidential
and the interview process shall be privileged. The interview question should be open-ended
so that the client can provide enough information to the healthcare provider. Adequate time is
also provided to the patient to provide all the required interruption and their responses are
free from any form of interruption. During the entire process, the healthcare provider is
supposed to observe the client’s verbal and non-verbal cues about specific questions.
Significant changes in cues may indicate wrong responses and may result in inaccurate
information. The healthcare provider is supposed to collect objective and subjective data
during the entire process. The interview process serves to collect all relevant information
regarding the health status of an individual.



Present Health Status and History of Presenting Illness
Patient X was born on November 20th 1975 and currently works as a medical
technologist at INOVA Alexandria. Patient X is the mother to four children, two boys and
two girls. Patient X obstetric history indicates occurrence of gravida for a total of six times,
two preterm events, two abortions or incomplete birth and currently has four children. Of the
four children, two were full term deliveries, and two were preterm. Two of the children were
also born through the natural approach while the remaining were born through cesarean
section. All the children have no complications and healthy. Patient X has not reported any
childhood injuries although the current reason for seeking healthcare services is due to an
increase in the level of blood pressure. Patient X has also reported allergies for pollen and
chloroquine. The current medication being provided to the patient is Nifedipine at 60mg once
per day and Metoprolol at 25 mg once per day. The last physical examination was carried out
on January 2020. The patient also reported a dental check up in December 2019 and a visual
checkup in August 2019. The patient also indicated that no other disease is common among
the family members except high blood pressure.
The interview was carried out in the home of Patient X. The patient seemed to be
well groomed and answered all questions positively. No major changes in the verbal and nonverbal expressions were observed while the interview was being carried out. Patient X largely
considered herself to be healthy although the family history of high blood pressure always
scared her. Patient X admitted that some of her lifestyle choices especially the choice of food
did little to manage high blood pressure. Patient X indicated consuming large amount of food
rich in salts as well as using food products that were rich in saturated fats that predisposed the
patient to cardiovascular conditions. Nonetheless, Patient X was hopeful that with the
required treatment she would report better outcomes. Patient X was also willing to change
some lifestyle habits in an effort to reduce the side effect and progress of the disease.


Medication Reconciliation

Patient X reported allergies to pollen and to chloroquine, a drug that is commonly
used to treat malaria and other autoimmune diseases. Currently, Patient X has been
prescribed two drugs; Nifedipine and Metoprolol. The patient indicates that she strictly
adheres to the prescriptions provided by the physician.
Nifedipine (60mg daily)
Patient X takes Nifedipine on a daily basis. The drug is classified as a calcium
channel blocker and is used to treat hypertension. It works by relaxing the muscles present in
the blood vessels and the heart and serves to increase movement of blood (Shekhar, Gupta,
Kirubakaran, & Pareek, 2016). Nifedipine can also be used to treat chest angina. Common
side effects associated with the use of Nifedipine include swelling of the arms, hands, lower
legs or feet, labored breathing, feeling of warmth, muscle cramps, shortness of breath,
tingling of feet, weakness, unusual weight loss or gain, and irregular pounding of the heart
(Shi, Yang, Zhou, & Wang, 2016).
Metoprolol (25mg daily)
The drug is a beta-blocker and affects the flow of blood in the veins and arteries. It is
commonly used in treating patients who report hypertension and chest pain. The drug lowers
and individual risk of dying especially when an individual report heart failure occasion by
high blood pressure (Lexicomp, 2016; Wong, Boyda, & Wright, 2016). Some common side
effects associated with the drug include chest pain or discomfort, blurred vision, dizziness,
sweating, unusual weakness or tiredness and confusion among the patients (Lexicomp, 2016;
Wong et al., 2016). The drugs should also be withdrawn gradually to avoid various side


Past Medical History. Surgeries, and Allergies

Patient X does not report any disease conditions while growing up. Nonetheless, it is
essential to note that x received all the required vaccinations at the required time. The
vaccinations included polio, rotavirus, varicella, Hepatitis A, Hepatitis B and Pneumococcal.
Patient X has also never undergone any major surgeries.
Patient X currently has four children; two boys and two girls. Two children were born
using the natural approach while the remaining two were born using cesarean section. Patient
X also indicated that occurrence of gravida for a total of six times, two preterm events, two
abortions or incomplete birth and currently has four children.
Patient X was diagnosed with high blood pressure a couple of years ago after
reporting difficulty in breathing and continued irregular heartbeats. On undergoing the
requited checkup, patient X was informed that her blood pressure levels were above the
normal level and therefore there was need to be immediately placed on the required
medication. Patient X was also informed of the need to change some of the common lifestyle
behaviors especially those related to diet.
On carrying out a complete background check, Patient X informed the healthcare
provider that most members across their family had also reported incidences of blood
pressure. More notably, Patient X grandmother died of hypertension a couple of years ago.
Patient X father was also on blood pressure medication for the past four years. Patient X
sister is also currently on similar medication while his brother is obese and was diagnosed
with a cardiovascular condition. Patient X has undergone three checkups in the last. The
checks revolved around a complete checkup, a dental check-up and a vision checkup. No
understanding issue were identified in the visual and dental checkup. The patient blood
pressure was still high during the entire period.


Social History

Patient X does not drink alcohol and has no history in the use of tobacco products.
The use of such substances is likely to increase the severity of the disease condition. The
patient indicates no use of any illegal drugs.
The genogram provided below shows the genetic inheritance of hypertension among
the family members including the suspected individuals. The main patient under investigation
is labelled X. From the genogram provided below, Patient X mother died at 70 years due to
the disease. Patient X father also has a history of hypertension. Only one sibling among the
four has not reported high blood pressure. Patient X husband also comes from a family with
reported cases of hypertension. All Patient X children are suspected to develop the disease in
the future.



female hypertension

male hypertension

normal female

suspected male

female dead


normal male

suspected female


Figure 1. Genogram highlighting presence of hypertension among family members.
Review of Systems
General Overall Health State
Patient X seemed to be upbeat about their medical condition. The systolic pressure
was high. Patient X strictly adhered to the provided medication and changed her lifestyle to
fit the current circumstances. Patient X is consuming less salts in foods and currently uses
vegetable oil. The patient does not report any severe signs and manages some of the side
effects of the disease significantly well
Patient X did not report any skin diseases. Nonetheless, Patient X reported the
presence of different moles in the body. These moles were not associated with any
abnormality. The patient regularly consults with other medical providers on which creams to
use to reduce the presence of moles.
Patient X has reported no incidences of headaches as well as changes in vision, ear,
nose problems or sore throats.



Respiratory System
Patient X report no previous incidences of lung disease. However, the patient report

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