Student Name: STUDENT B 1. Demographic Data Name: (Initials) BM Gender: Female Birth Date: 02/10/1993 Age: 25 years Occupation: Patient Safety Assistant mystic Race/Ethnic origin: African Hospital Birthplace: Merrillville, Indiana Marital Status: Married Religion: Employer: St. Vincent Source and Reliability: Self Reason for seeking care: Physical Present Health or History of Present Illness: Good overall health Perception of Own Health: Good overall health Past Health: Arthritis, Pneumonia, PTSD, Blood Clots, Lower back pain, Kidney Stones, anxiety, panic disorder, depression Obstetric History:N/A G: T: P: A: L: Immunizations: Up to date Last examination date: Nov 2018 Allergies: Seasonal Reaction: Any treatment: Zyrtec Current Medications: Bupropion, Topamax, Omeprazole, Propanol, Cyanocobalamin, promethazine, fluticasone propionate nasal spray, Multi Vitamin, B1, Iron, Vitamin D3, Probiotic, Family History: High BP, Arthritis, Allergies Review of Systems: height 5’6 ft. weight 147 BMI 23 Skin: skin is uniform in color some blemishs good turgor Hair: No hair loss, hair is thick and kinky evenly distributed Nails: moderately healthy nails Head: migraine headaches Eyes: astigmatism, wears glasses Ears: During assessment passed hearing test, auricles symmetrical and the same color with facial skin. The auricles are aligned with the outer canthus of eye. Nose and Sinuses: No areas of concern Mouth and Throat: past: tonsillectomy Breast: does monthly self-breast exams Respiratory System: past: pneumonia often Cardiovascular System: No areas of concern, patient frequently exercises Peripheral Vascular System: No areas of concern Gastrointestinal System: No areas of concern Urinary System: No areas of concern Genital System: past: unilateral salpingo-oophorectomy Current: ovarian cyst, PCOS Sexual Health: No contraceptives Musculoskeletal System: knee and wrist inflammation Neurologic System: No areas of concern Hematologic System: Blood clot right portal vein Endocrine System: PCOS, pituitary adenoma Developmental considerations: no developmental considerations Cultural considerations: no cultural concerns Psychosocial considerations: no psychosocial considerations If you were to perform a physical assessment, which body system would be a top priority for evaluation and why? List two teaching/learning need priorities for this individual (Consider Age, Psychosocial, Cultural, Lifespan concerns) I would advise my patient to continue her monthly self-breast exams to maintain overall good health Collaborative resources (Think Community, Family, Groups, Health Care System) REFLECTION – 40 points-this is just a framework; please see grading rubric for full information Be sure your reflection addresses each of these questions: • • • • • • • • • How did your interaction compare to what you have learned? What went well? What barriers to communication did you experience? How did you overcome them? What will you do to overcome them in the future? Were there unanticipated challenges to the interview? Was there information you wished you had obtained? How will you alter your approach next time? Full Examination 1 Complete Adult Assessment: Full Examination Patient: Chelsea Hinnegan Nurse: Allison Wintin Health Assessment II Dr. Bell December 6, 2018 RUNNING HEAD: Full Examination 2 Health History Student Name: 1. Demographic Data Name: (Initials) CNH Gender: F Birth Date: November 7th, 1991 Age: 26 Occupation: Vet Tech Race/Ethnic origin: Caucasian Birthplace: Altamote, FL Marital Status: M Religion: No preference Employer: None Source and Reliability: Self Reason for seeking care: Physical Present Health or History of Present Illness: Good Perception of Own Health: Good Past Health: Obstetric History: 2 pregnancies G: 2 T: 2 P:0 A: 0 L: 2 Course of pregnancy: 1st kid- Female, 39 weeks, 6 days, 6 hour labor, 6lbs 4oz, vaginal birth, no complications 2nd kid- Female, 39 weeks, 5 days, 5 hour labor, 7lbs 3 oz, vaginal birth, no complications Immunizations: Hep B, TDAP, Varicella, MMR, Flu Last examination date: January 2018 Allergies: Neosporin Reaction: blisters Any treatment: don’t use the medication Current Medications: birth control pills Family History Heart disease- maternal grandfather Diabetes- maternal grandmother Ovarian cancer- mother Cancer- uncle, melanoma Arthritis- parents, grandparents Allergies- mother, penicillin Asthma- sister Alcoholism and drug addiction- father RUNNING HEAD: Full Examination 3 Review of Systems: height 5’ 1” weight 135lbs BMI 25 Skin: No present skin issues Hair: pregnancy changed texture Nails: No recent color change or brittleness Head: 3 concussions in past, has lead to neurological damage on the back of her skull Eyes: Astigmatism in left eye- wears corrective glasses Ears: No known ear issues Nose and Sinuses: No nose or sinus issues Mouth and Throat: No sores or sore throat. No swallowing issues Breast: No breast issues. Performs monthly self exam Respiratory System: Exercise induced asthma Cardiovascular System: Anesthesia sometimes causes SBT Peripheral Vascular System: No toes or limb problems Gastrointestinal System: No vomiting or stomach issues Urinary System: urination not painful or odd color Genital System: last menstrual cycle – 13 Aug 18 Sexual Health: Married relationship with monogamous sexual intercourse. Using birth control pills Musculoskeletal System: No pain of stiffness in joints Neurologic System: No history of arthritis or gout Hematologic System: No known blood disorders Endocrine System: No history or symptoms of diabetes RUNNING HEAD: Full Examination 4 Developmental considerations – Adulthood. Can make informed decisions and understands information presented. Cultural considerations – No religious or cultural considerations in regards to healthcare. Psychosocial considerations – She has accomplished intimacy vs. isolation If you were to perform a physical assessment, which body system would be a top priority for evaluation and why? Cardiovascular system would be my first assessment because there is a history of heart disease. List two teaching/learning need priorities for this individual (Consider Age, Psychosocial, Cultural, Lifespan concerns) 1. She learns by hands on experiences so I would ensure that anything that she needs to do at home, she could demonstrate in office. 2. She has kids so I would teach her how to properly store and dispose of old medication to keep her children safe. Collaborative resources (Think Community, Family, Groups, Health Care System) Neighbor game night to keep stress levels low. Plays soccer in adult league. Functional Assessment Self-Concept- Client views herself as mostly successful. She feels accomplished because out of her family on both sides she is one of few who have obtained a degree and furthered her education after high school. She and her husband own their own home and have two healthy children. Activity-exercise- Client has maintained a very healthy and active lifestyle for the past 7 years. She ran a half marathon while 6 months pregnant with her youngest child and has maintained a healthy activity level until injuring her right ACL. For the last 3 months she has not been as active and has gained weight as a result. Sleep-rest- Client awakens throughout the night most nights and does not feel well rested most days. She continuously awakens to urinate in the night and will lay awake in bed unable to fall back to sleep for hours. RUNNING HEAD: Full Examination 5 Nutrition- Client tries to eat healthy for the most part but does occasionally eat out at restraunts and eats friend foods. Client does take a women’s gummy multi-vitamin. There are no food allergies or intolerances that she is aware of. Alcohol- Client does drink approximately a bottle of wine about twice a week. She may drink more than that in a social setting with friends and neighbors. Interpersonal Relationships- Client’s parents got divorced when she was 7 years of age. Their relationship was verbally and physically abusive their entire relationship. She had witnessed several occasions where her parents got into physical fights and one would try to kill the other. On several occasions, she had to move with her mom and sister to another city or town to get out of the situation. There was a lot of alcohol and drug usage by her father and that hindered their ability to spend time with him even on his designated custody weekends. Her relationship with her sister is probably the tightest and most positive relationship she had until she met her husband in 2008. The relationship she has with her husband is a very close bond and they tend to avoid conflict by discussing rather than verbally and physically fighting. Not once has she and her husband been in a physical altercation. Coping and Stress management- Client uses physical exercise as her stress relieve and coping mechanism. The harder she pushes herself physically in a workout the better she feels emotionally afterwards. This has changed recently with her injury to her knee and has realized she has indulged in drinking wine as a source of release from stress. She has started to change this back to physical exercise with the healing of her knee. RUNNING HEAD: Full Examination 6 Perception of Health Client feels she is in good health but that it could most definitely be improved by getting back on her normal diet of fresh fruits and vegetables 3 times a day and regular physical activity again. Physical Examination Skin: Client has no visible lesions and her skin is pale pink in color with an even tone throughout. She does have several small dime sized bruises throughout her lower extremities. The medication she is on (Citalopram) has a side effect of easy bruising. Her nails are clean and no spooning or other defects present. Capillary refill within is 2 seconds. She also notes to be a nail biter. Head: Normocephalic. No bumps or tender areas. No infestation present. Client does have nerve damage on the back of her skull to the right of the midline above occipital lobe due to head injury in 2013. Eyes: PERRLA is noted. Sclera is white and surrounded by a pink, moist conjunctiva. CN III, IV, and VI present and working appropriately. No ptosis or drainage is noted. She does wear glasses /corrective lenses so eyesight unaided is not 20/20. Ears: Pinna are equal with no noted masses, lesions or pain. Tympanic membrane intact bilaterally and there is no swelling or redness noted. Client is able to repeat words verbalized heard in both ears. Nose: Patient does not have any evidence of a deviated septum and does not have any breathing restrictions in nostrils. She does have a crease in the tip of her nose from frequent rubbing of nose as a child. RUNNING HEAD: Full Examination 7 Mouth: Clients lips, gums, and teeth are all intact with no visible lesions, cold sores, or deformities. All teeth are accounted for in her mouth. CN IX and X are noted to be intact when client says “ah” and uvula raises with the roof of the mouth. CN XII is noted to be intact when client sticks out her tongue and there is no issue with movement or twitching motions. Mucus membranes are pink and moist, and no lesions noted. Client does have mandibular tori bilaterally. This does not currently present any issues with salivary production or eating. Neck: Client has full ROM in neck. She does complain of stiffness in the left side of her neck due to improper position during sleep the night before. Jugular vein distention is not noted, and carotid arteries are bilaterally palpated at 2+. No cervical lymph nodes palpated. Spine and Back: Client was in a car accident in 2009 where she was jerked in the front seat of the car. Since then, she has had CHR pain in her lower back when sitting or slouching too long. Client does not have any scoliosis or kyphosis. She did experience lordosis during both her pregnancies and has some back pain occasionally associated with this. Thorax and Lungs: Client’s AP < transverse. No adventitious lung sounds noted and she has symmetrical expansion with inhalation and symmetrical decompression of chest wall when exhaling. Tactile fremitus is noted bilaterally. Breasts: Client breast fed both of her children and recently discontinued breast feeding her youngest approximately 6 months ago. She has just now stopped feeling the tingling sensation in her breast during menstruation. Stretch marks are noted on both breasts. There are no lumps or pain noted in either breast. RUNNING HEAD: Full Examination 8 Heart: Family history of heart problems but currently does not have any issues. The apical pulses is noted during auscultation and palpated while lying down. No abnormal sounds heard upon auscultation. Normal S1 and S2 is heard. Abdomen: No physical defects noted upon inspection. There are scars noted from her appendectomy. Normal bowel sounds are noted in all 4 quadrants. No tenderness is noted upon palpation in all 4 quadrants. Extremities: Full ROM in extremities. No pain or discomfort noted and skin feels warm to the touch. Musculoskeletal: Full ROM is noted within all major joints. Crepitus is noted in both knees bilaterally. Both thumbs make a popping sound at the 2nd joint when bent. Client is able to move joints without pain most days. Neurologic: Client is aware of surroundings and has full motor and sensory function when addressed and approached. No tingling or twitching is noted anywhere on the body. Needs Assessment 1. The client could benefit from more information on coping with stress as an alternative to her current method. This would include decreasing her alcohol consumption. Client has a high stress level and has, on average, a bottle of wine twice a week to cope. Occasionally the individual will have more than that in a social setting with friends. Though her social group allows her to have fun and destress from the work week, it has become more of a ritual to consume a large amount of alcohol when getting together. Large amounts of alcohol can add to the stress on the mental and physical state of the body. The client RUNNING HEAD: Full Examination 9 should incorporate other ways of dealing with stress. Some ways to relieve stress would be to set aside some time for herself to be alone and decompress, exercising regularly, and eating a healthier diet. Getting at least 30 minutes of exercise each day can have a positive effect on energy and mood. Foods high in nutrients and low in fat also help the body to feel more energized and less bloated. 2. With the clients’ history of knee injuries, it would be best to incorporate an exercise program that decreases further injury. There are several ways in which to decrease or eliminate further injury. Implementing more flexibility exercises, running, strength training, core exercises, and plyometrics are the most basic ways to build body strength while minimizing injury. Arundale, Buzzing, and Giordano outline more than a hundred exercises that fall within these categories in the article Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. Some of these include planking, squats, steady paced jogging, and warm up exercises to loosen muscles prior to heavy workouts. By incorporating these body weight exercises more frequently, the muscles will build more mass to take some of the stress and pressure off the joints. This includes the knee. RUNNING HEAD: Full Examination 10 Reflection My interview with the client happened around 10am on a Tuesday. We were in an open area with limited privacy. When learning about what how to interview and obtain a health history from a client, you are supposed to be in a closed room with just you and the client. This was impossible given the circumstances, but we made it work. We also didn’t really talk about how it may be awkward for you and the client. There are questions that need to be asked that may embarrass some people and the answers may embarrass or shock the provider. There were a few subjects that you could tell made the client a little uncomfortable to answer and a few made me uncomfortable to ask. Overall, the interaction went well. I introduced myself and told the client what I was going to be doing during the interview. I then started asking her questions about herself, and her family history to ensure that I had the bigger picture of her health. After we got over some of the embarrassing questions, we were able to talk more openly and honestly. I think that we both just had to break the ice and understand that there was no judgment, but the questions pertained to her health and needed to be answered. Almost everything in the interview went well. We were both able to take it seriously and ask/answer the hard and personal questions without laughing or feeling totally uncomfortable. Also, I felt like she was became comfortable enough with me to share things that aren’t easy to talk about or not many people know. I didn’t experience any barriers of communication because we both speak English and neither one of us use any slang references or terms so we both understood each other quite well. I would say the only barrier that I ran into was that we were basically strangers when I was conducting this interview and had to ask some deep, and personal questions. I think that we overcame this barrier by remaining professional and courteous of each other and understanding that some of the questions are sensitive and can cause an emotional reaction. RUNNING HEAD: Full Examination 11 In the future, I now know how personal some of the questions and topics will be. I will prepare my client by telling them that I will be asking some questions that might make them uncomfortable and they don’t have to answer them. I will also let them know that with HIPAA, I am not allowed to take any information outside of the office so anything that they say to me, no matter how embarrassing or personal, will stay in the office. Hopefully this will calm their nerves enough to be open and honest. The unanticipated challenge that I experienced was that this was my first time doing a complete health history and I really didn’t know what to expect or how I would react to having to ask some of the things that are required to know. As time goes on and I do more and more of these assessments, it will get easier and I will be able to flow through it much smoother. In this interview, it really helped that she was very open and honest with me, so I don’t think that I missed any information. I feel confident that I know her family history, as well as her health history. I completed a full assessment and I don’t think I left anything out. I will practice my approach to an assessment and get better at it. I want to get to a point that I can flow through the questions without having to follow a prompt. I want to be able to maintain eye contact throughout most of the interview, and not constantly be looking at my notes or writing stuff down frantically. I think that with time and practice, this assessment will come easily. My eyes will become trained to look for things and I will pick up on nonverbal gestures easier. This was definitely eye opening and something that I need to practice because I will be doing it on a daily basis. RUNNING HEAD: Full Examination 12 References ARUNDALE, A. J. H., BIZZINI, M., GIORDANO, A., HEWETT, T. E., LOGERSTEDT, D. S., MANDELBAUM, B., … SNYDER-MACKLER, L. (2018). Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. Journal of Orthopaedic & Sports Physical Therapy, 48(9), A41–A42. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx? direct=true&db=s3h&AN=131637281&site=eds-live&scope=site McCoy, K. (2016). Alcohol and Stress: There are Safer Ways to Cope. Health Library: Evidence-Based Information. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx? direct=true&db=nup&AN=2009805999&site=eds-live&scope=site Running Head: HEALTH ASSESSMENT REFLECTION Health Assessment Reflection Chamberlain University NR 203 Professor Grose Donna Fagarang 29 Sep 2018 1 Running Head: HEALTH ASSESSMENT REFLECTION 2 Prior to this interview, my expectations were high due to the kind of information I was seeking seemed easy and personal. Health is the most important aspect of human living which should be taken seriously to ensure that an individual is aware of their situation and how they can shape their lifestyles to live comfortably. I, therefore, hoped that the subject will be aware of these details and answer the questions of the interview with much ease. It was however different when the process began as the individual seemed disconnected from the issues at hand. The only answers I received without any challenges were the basic ones concerning age, gender, name, occupation, race, religion and status. However, when it came to health history and possible conditions that the subject might be experiencing, we had to slow down. The interview, therefore, took longer than expected and diverted to more questions that would help in retrieving the required answers. The interviewee was however cooperative and made sure to confirm any details that sounded unclear during the course of the interview. The information received seemed accurate as there were no contradictions when comparing the different issues. The subject was also easy to deal with as he was not afraid of giving out personal information as many would be when dealing with a research process. He also had some medical documents that I checked to get the idea of several the family history which is an important ideology for the interview. There were, however, communication challenges I experienced that made it hard to accomplish different objectives. Some concepts are too technical in the medical aspect which gave us a difficult time relating. For example, when I asked the interviewee about their neurologic and endocrine systems, he was just looking at me as the terms are biologically limiting. The individual was not in a position to answer these details as he had not consulted doctors before concerning the same. Running Head: HEALTH ASSESSMENT REFLECTION 3 Although I am not an expert in the field, I tried to explain some of these technical words to the subject although it was not easy as he still found the information confusing. I also tried to add other simpler questions related to the content of the interview that I thought could make more sense. They were addressing the same ideas but I found a way of putting them out in a way that any individual who does not even have a medical background can comprehend. A future similar interview will be much successful as I will prepare prior to the interaction to make things much easier. I will ensure to explain every detail of the questions to the subject and reduce any misunderstandings that might drag behind the process of information acquisition. I was hopeful to get the basics form the interviewee as the detail would help in conducting the medical research which aims at comparing the different aspect of an individual’s health. Finally I will be responsible for educating the individual even before asking the questions to ensure that they have the general background of the different concepts involved. A person finds it more convenient when they are talking about issue they already know and as the nurse in charge, it is my duty to ensure that they get to understand these aspects. Chamberlain College of Nursing NR304 Health Assessment II REQUIRED UNIFORM ASSIGNMENT GUIDELINES 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 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) CO 6: Identify teaching/learning needs from the health history of an individual. (POs 2, 5) 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. 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 in NR 304 RUA Grading Rubric and Grading Criteria V1.docx 10_16 SMa Revised 05/31/17 SP/nlh 1 Chamberlain College of Nursing NR304 Health Assessment II 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 o Neurological system o Gastrointestinal system o Musculoskeletal system o Peripheral vascular system NR 304 RUA Grading Rubric and Grading Criteria V1.docx 10_16 SMa Revised 05/31/17 SP/nlh 2 Chamberlain College of Nursing NR304 Health Assessment II ***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 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. NR 304 RUA Grading Rubric and Grading Criteria V1.docx 10_16 SMa Revised 05/31/17 SP/nlh 3 Chamberlain College of Nursing NR304 Health Assessment II 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 V1.docx 10_16 SMa Revised 05/31/17 SP/nlh 4 Chamberlain College of Nursing NR304 Health Assessment II DIRECTIONS AND GRADING CRITERIA Category Health History and Physical Assessment Points % 50 50 Description 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 peerreviewed 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 NR 304 RUA Grading Rubric and Grading Criteria V1.docx 10_16 SMa Revised 05/31/17 SP/nlh 4 Chamberlain College of Nursing NR304 Health Assessment II 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. 100 100 Total NR 304 RUA Grading Rubric and Grading Criteria V1.docx 10_16 SMa Revised 05/31/17 SP/nlh 5 Very Good or High Level of Performance C (76–83%) Competent or Satisfactory Level of Performance F (0–75%) Poor, Failing or Unsatisfactory Level of Performance NR304 Health Assessment II Outstanding or Highest Level of Performance B (84–91%) 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 GRADING RUBRIC A (92–100%) 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 Chamberlain College of Nursing Assignment Criteria Health History and Physical Examination (50 points) 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 4 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 SP/nlh 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 Revised 05/31/17 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 10_16 SMa 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 Thoroughly presents a physical exam narrative that includes a detailed description of all the following components HEENT Neurological system Neck Respiratory system NR 304 RUA Grading Rubric and Grading Criteria V1.docx • • • 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 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. 42-45 points 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. 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. 38-41 points 5 Broadly appraises the individual. Three or more of the following 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 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. 0–37 points Information is not presented in a clear, organized, and professional manner. Musculoskeletal system Peripheral vascular system Integumentary system integrated in exam of all systems where appropriate NR304 Health Assessment II Peripheral vascular system Integumentary system integrated in exam of all systems where appropriate 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 but does not use appropriate APA format (most current edition) to list the sources. 16 points Information is not presented in a clear, organized, and professional manner. 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. 17-18 points Information is presented in a clear, organized, and professional manner. 19-20 points SP/nlh Broadly appraises the individual. Two of the following questions Revised 05/31/17 Thoughtfully appraises the individual holistically. One of the following questions is not 10_16 SMa Thoughtfully appraises the individual holistically. Reflection Cardiovascular system Gastrointestinal system Musculoskeletal system Peripheral vascular system Integumentary system integrated in exam of all systems where appropriate Chamberlain College of Nursing Needs Assessment (20 Points) Reflection (20 Points) NR 304 RUA Grading Rubric and Grading Criteria V1.docx 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. 17-18 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? 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. Key and relevant information is presented in insufficient detail but is clear and organized. 8 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? 0–7 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. Key and relevant information is presented in insufficient detail and is not clear or organized. 0–7 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? NR304 Health Assessment II Key and relevant information is presented in sufficient detail and is clear and organized. 19-20 points 8 points Chamberlain College of Nursing Writing Style and Format (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 Revised 05/31/17 SP/nlh Total Points Possible = 100 points 10_16 SMa 6 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 NR 304 RUA Grading Rubric and Grading Criteria V1.docx Full Examination 1 Complete Adult Assessment: Full Examination Patient: Chelsea Hinnegan Nurse: Allison Wintin Health Assessment II Dr. Bell December 6, 2018 RUNNING HEAD: Full Examination 2 Health History Student Name: 1. Demographic Data Name: (Initials) CNH Gender: F Birth Date: November 7th, 1991 Age: 26 Occupation: Vet Tech Race/Ethnic origin: Caucasian Birthplace: Altamote, FL Marital Status: M Religion: No preference Employer: None Source and Reliability: Self Reason for seeking care: Physical Present Health or History of Present Illness: Good Perception of Own Health: Good Past Health: Obstetric History: 2 pregnancies G: 2 T: 2 P:0 A: 0 L: 2 Course of pregnancy: 1st kid- Female, 39 weeks, 6 days, 6 hour labor, 6lbs 4oz, vaginal birth, no complications 2nd kid- Female, 39 weeks, 5 days, 5 hour labor, 7lbs 3 oz, vaginal birth, no complications Immunizations: Hep B, TDAP, Varicella, MMR, Flu Last examination date: January 2018 Allergies: Neosporin Reaction: blisters Any treatment: don’t use the medication Current Medications: birth control pills Family History Heart disease- maternal grandfather Diabetes- maternal grandmother Ovarian cancer- mother Cancer- uncle, melanoma Arthritis- parents, grandparents Allergies- mother, penicillin Asthma- sister Alcoholism and drug addiction- father RUNNING HEAD: Full Examination 3 Review of Systems: height 5’ 1” weight 135lbs BMI 25 Skin: No present skin issues Hair: pregnancy changed texture Nails: No recent color change or brittleness Head: 3 concussions in past, has lead to neurological damage on the back of her skull Eyes: Astigmatism in left eye- wears corrective glasses Ears: No known ear issues Nose and Sinuses: No nose or sinus issues Mouth and Throat: No sores or sore throat. No swallowing issues Breast: No breast issues. Performs monthly self exam Respiratory System: Exercise induced asthma Cardiovascular System: Anesthesia sometimes causes SBT Peripheral Vascular System: No toes or limb problems Gastrointestinal System: No vomiting or stomach issues Urinary System: urination not painful or odd color Genital System: last menstrual cycle – 13 Aug 18 Sexual Health: Married relationship with monogamous sexual intercourse. Using birth control pills Musculoskeletal System: No pain of stiffness in joints Neurologic System: No history of arthritis or gout Hematologic System: No known blood disorders Endocrine System: No history or symptoms of diabetes RUNNING HEAD: Full Examination 4 Developmental considerations – Adulthood. Can make informed decisions and understands information presented. Cultural considerations – No religious or cultural considerations in regards to healthcare. Psychosocial considerations – She has accomplished intimacy vs. isolation If you were to perform a physical assessment, which body system would be a top priority for evaluation and why? Cardiovascular system would be my first assessment because there is a history of heart disease. List two teaching/learning need priorities for this individual (Consider Age, Psychosocial, Cultural, Lifespan concerns) 1. She learns by hands on experiences so I would ensure that anything that she needs to do at home, she could demonstrate in office. 2. She has kids so I would teach her how to properly store and dispose of old medication to keep her children safe. Collaborative resources (Think Community, Family, Groups, Health Care System) Neighbor game night to keep stress levels low. Plays soccer in adult league. Functional Assessment Self-Concept- Client views herself as mostly successful. She feels accomplished because out of her family on both sides she is one of few who have obtained a degree and furthered her education after high school. She and her husband own their own home and have two healthy children. Activity-exercise- Client has maintained a very healthy and active lifestyle for the past 7 years. She ran a half marathon while 6 months pregnant with her youngest child and has maintained a healthy activity level until injuring her right ACL. For the last 3 months she has not been as active and has gained weight as a result. Sleep-rest- Client awakens throughout the night most nights and does not feel well rested most days. She continuously awakens to urinate in the night and will lay awake in bed unable to fall back to sleep for hours. RUNNING HEAD: Full Examination 5 Nutrition- Client tries to eat healthy for the most part but does occasionally eat out at restraunts and eats friend foods. Client does take a women’s gummy multi-vitamin. There are no food allergies or intolerances that she is aware of. Alcohol- Client does drink approximately a bottle of wine about twice a week. She may drink more than that in a social setting with friends and neighbors. Interpersonal Relationships- Client’s parents got divorced when she was 7 years of age. Their relationship was verbally and physically abusive their entire relationship. She had witnessed several occasions where her parents got into physical fights and one would try to kill the other. On several occasions, she had to move with her mom and sister to another city or town to get out of the situation. There was a lot of alcohol and drug usage by her father and that hindered their ability to spend time with him even on his designated custody weekends. Her relationship with her sister is probably the tightest and most positive relationship she had until she met her husband in 2008. The relationship she has with her husband is a very close bond and they tend to avoid conflict by discussing rather than verbally and physically fighting. Not once has she and her husband been in a physical altercation. Coping and Stress management- Client uses physical exercise as her stress relieve and coping mechanism. The harder she pushes herself physically in a workout the better she feels emotionally afterwards. This has changed recently with her injury to her knee and has realized she has indulged in drinking wine as a source of release from stress. She has started to change this back to physical exercise with the healing of her knee. RUNNING HEAD: Full Examination 6 Perception of Health Client feels she is in good health but that it could most definitely be improved by getting back on her normal diet of fresh fruits and vegetables 3 times a day and regular physical activity again. Physical Examination Skin: Client has no visible lesions and her skin is pale pink in color with an even tone throughout. She does have several small dime sized bruises throughout her lower extremities. The medication she is on (Citalopram) has a side effect of easy bruising. Her nails are clean and no spooning or other defects present. Capillary refill within is 2 seconds. She also notes to be a nail biter. Head: Normocephalic. No bumps or tender areas. No infestation present. Client does have nerve damage on the back of her skull to the right of the midline above occipital lobe due to head injury in 2013. Eyes: PERRLA is noted. Sclera is white and surrounded by a pink, moist conjunctiva. CN III, IV, and VI present and working appropriately. No ptosis or drainage is noted. She does wear glasses /corrective lenses so eyesight unaided is not 20/20. Ears: Pinna are equal with no noted masses, lesions or pain. Tympanic membrane intact bilaterally and there is no swelling or redness noted. Client is able to repeat words verbalized heard in both ears. Nose: Patient does not have any evidence of a deviated septum and does not have any breathing restrictions in nostrils. She does have a crease in the tip of her nose from frequent rubbing of nose as a child. RUNNING HEAD: Full Examination 7 Mouth: Clients lips, gums, and teeth are all intact with no visible lesions, cold sores, or deformities. All teeth are accounted for in her mouth. CN IX and X are noted to be intact when client says “ah” and uvula raises with the roof of the mouth. CN XII is noted to be intact when client sticks out her tongue and there is no issue with movement or twitching motions. Mucus membranes are pink and moist, and no lesions noted. Client does have mandibular tori bilaterally. This does not currently present any issues with salivary production or eating. Neck: Client has full ROM in neck. She does complain of stiffness in the left side of her neck due to improper position during sleep the night before. Jugular vein distention is not noted, and carotid arteries are bilaterally palpated at 2+. No cervical lymph nodes palpated. Spine and Back: Client was in a car accident in 2009 where she was jerked in the front seat of the car. Since then, she has had CHR pain in her lower back when sitting or slouching too long. Client does not have any scoliosis or kyphosis. She did experience lordosis during both her pregnancies and has some back pain occasionally associated with this. Thorax and Lungs: Client’s AP < transverse. No adventitious lung sounds noted and she has symmetrical expansion with inhalation and symmetrical decompression of chest wall when exhaling. Tactile fremitus is noted bilaterally. Breasts: Client breast fed both of her children and recently discontinued breast feeding her youngest approximately 6 months ago. She has just now stopped feeling the tingling sensation in her breast during menstruation. Stretch marks are noted on both breasts. There are no lumps or pain noted in either breast. RUNNING HEAD: Full Examination 8 Heart: Family history of heart problems but currently does not have any issues. The apical pulses is noted during auscultation and palpated while lying down. No abnormal sounds heard upon auscultation. Normal S1 and S2 is heard. Abdomen: No physical defects noted upon inspection. There are scars noted from her appendectomy. Normal bowel sounds are noted in all 4 quadrants. No tenderness is noted upon palpation in all 4 quadrants. Extremities: Full ROM in extremities. No pain or discomfort noted and skin feels warm to the touch. Musculoskeletal: Full ROM is noted within all major joints. Crepitus is noted in both knees bilaterally. Both thumbs make a popping sound at the 2nd joint when bent. Client is able to move joints without pain most days. Neurologic: Client is aware of surroundings and has full motor and sensory function when addressed and approached. No tingling or twitching is noted anywhere on the body. Needs Assessment 1. The client could benefit from more information on coping with stress as an alternative to her current method. This would include decreasing her alcohol consumption. Client has a high stress level and has, on average, a bottle of wine twice a week to cope. Occasionally the individual will have more than that in a social setting with friends. Though her social group allows her to have fun and destress from the work week, it has become more of a ritual to consume a large amount of alcohol when getting together. Large amounts of alcohol can add to the stress on the mental and physical state of the body. The client RUNNING HEAD: Full Examination 9 should incorporate other ways of dealing with stress. Some ways to relieve stress would be to set aside some time for herself to be alone and decompress, exercising regularly, and eating a healthier diet. Getting at least 30 minutes of exercise each day can have a positive effect on energy and mood. Foods high in nutrients and low in fat also help the body to feel more energized and less bloated. 2. With the clients’ history of knee injuries, it would be best to incorporate an exercise program that decreases further injury. There are several ways in which to decrease or eliminate further injury. Implementing more flexibility exercises, running, strength training, core exercises, and plyometrics are the most basic ways to build body strength while minimizing injury. Arundale, Buzzing, and Giordano outline more than a hundred exercises that fall within these categories in the article Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. Some of these include planking, squats, steady paced jogging, and warm up exercises to loosen muscles prior to heavy workouts. By incorporating these body weight exercises more frequently, the muscles will build more mass to take some of the stress and pressure off the joints. This includes the knee. RUNNING HEAD: Full Examination 10 Reflection My interview with the client happened around 10am on a Tuesday. We were in an open area with limited privacy. When learning about what how to interview and obtain a health history from a client, you are supposed to be in a closed room with just you and the client. This was impossible given the circumstances, but we made it work. We also didn’t really talk about how it may be awkward for you and the client. There are questions that need to be asked that may embarrass some people and the answers may embarrass or shock the provider. There were a few subjects that you could tell made the client a little uncomfortable to answer and a few made me uncomfortable to ask. Overall, the interaction went well. I introduced myself and told the client what I was going to be doing during the interview. I then started asking her questions about herself, and her family history to ensure that I had the bigger picture of her health. After we got over some of the embarrassing questions, we were able to talk more openly and honestly. I think that we both just had to break the ice and understand that there was no judgment, but the questions pertained to her health and needed to be answered. Almost everything in the interview went well. We were both able to take it seriously and ask/answer the hard and personal questions without laughing or feeling totally uncomfortable. Also, I felt like she was became comfortable enough with me to share things that aren’t easy to talk about or not many people know. I didn’t experience any barriers of communication because we both speak English and neither one of us use any slang references or terms so we both understood each other quite well. I would say the only barrier that I ran into was that we were basically strangers when I was conducting this interview and had to ask some deep, and personal questions. I think that we overcame this barrier by remaining professional and courteous of each other and understanding that some of the questions are sensitive and can cause an emotional reaction. RUNNING HEAD: Full Examination 11 In the future, I now know how personal some of the questions and topics will be. I will prepare my client by telling them that I will be asking some questions that might make them uncomfortable and they don’t have to answer them. I will also let them know that with HIPAA, I am not allowed to take any information outside of the office so anything that they say to me, no matter how embarrassing or personal, will stay in the office. Hopefully this will calm their nerves enough to be open and honest. The unanticipated challenge that I experienced was that this was my first time doing a complete health history and I really didn’t know what to expect or how I would react to having to ask some of the things that are required to know. As time goes on and I do more and more of these assessments, it will get easier and I will be able to flow through it much smoother. In this interview, it really helped that she was very open and honest with me, so I don’t think that I missed any information. I feel confident that I know her family history, as well as her health history. I completed a full assessment and I don’t think I left anything out. I will practice my approach to an assessment and get better at it. I want to get to a point that I can flow through the questions without having to follow a prompt. I want to be able to maintain eye contact throughout most of the interview, and not constantly be looking at my notes or writing stuff down frantically. I think that with time and practice, this assessment will come easily. My eyes will become trained to look for things and I will pick up on nonverbal gestures easier. This was definitely eye opening and something that I need to practice because I will be doing it on a daily basis. RUNNING HEAD: Full Examination 12 References ARUNDALE, A. J. H., BIZZINI, M., GIORDANO, A., HEWETT, T. E., LOGERSTEDT, D. S., MANDELBAUM, B., … SNYDER-MACKLER, L. (2018). Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. Journal of Orthopaedic & Sports Physical Therapy, 48(9), A41–A42. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx? direct=true&db=s3h&AN=131637281&site=eds-live&scope=site McCoy, K. (2016). Alcohol and Stress: There are Safer Ways to Cope. Health Library: Evidence-Based Information. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx? direct=true&db=nup&AN=2009805999&site=eds-live&scope=site