Fluent Essays

Everything you are going to need is the attachment and don’t forget to do as it ask.  P.S please follow the instructions in the instructions box images. This paper is very important. Use the scholarly articles that are less than 5 years published and one from the book we are using in the class.  Dont forget to go over the rubric while you write the paper. I need 4-5 pages not including title and references page Thank youNR304 Health Assessment II RUA Health History and Physical Assessment Guidelines NR304_Health_History_and_Physical_Assessment_Guidelines_V6_Final 1 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. 1. 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. 2. 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: This assignment enables the student to meet the following course outcomes. CO 1: 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 and 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 5: 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 and 5) CO 7: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (POs 6 and 7) Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment. Total points possible: 100 points Preparing the assignment Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions. 1. Complete a health history and physical examination on an individual. 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 NR304. The person interviewed must be 18 years of age Chamberlain University College of Nursing Health Assessment 2 Dr. Christina Johnson Assignment Due Date: Well Woman Check-up Demographic Data Mrs. R.K.B, a female African American aged 25, visited the hospital at Sugarland for her yearly well-woman visit on September 21st, 2020. A happily married woman who decided to go back to school as a full-time student. She is a mother of two children, a male, and a female.  Past Medical History She stated, and her medical record shows she had completed her tetanus, hepatitis, chickenpox, and MMR earlier as a child. She had no records of surgeries or any hospitalization history. The patient has never had a blood transfusion. Mrs. R.K.B has been diagnosed with strep throat in the past. Present Medication She is currently on prescribed medication like Ibuprofen 400mg PRN for pains. She is also on Calcium Acetate 667mg once daily for bone formation. She also takes vitamin C 500mg once a day to boost her immune system. Perception of Health Mrs. R.K.Bs perception of her health condition is good as she feels she is healthy and good. Compared to the regular African Americans who struggle with high blood pressure, diabetes, and high cholesterol due to their sedentary lifestyle. Also, most African America the same age as Mrs. R.K.B do not take the time to visit the hospital because of a lack of insurance, or they feel they are healthy so, they do not need to visit the hospital. The patient has an allergic reaction to chloroquine, she stated it irritates her skin, and she swells around her eyes.  Present Illness Mrs. R.K.B engages in vigorous exercise 4 times a week for 30 mins, and she tries to keep fit to be able to care for her family. Her last well-woman checkup was okay, which the nurse educator encouraged her to continue performing this checkup to prevent and review her reproductive health from time to time (Jarvis & Eckhardt, 2020). The patient currently is a nursing student so, she is aware of the implication of an unhealthy diet, and her salt intake is medium because she is knowledgeable of what a high intake of sodium can do to people mostly, African Americans. So, at this time of the visit, the patient has no illness. Family Medical History Her mother was diagnosed with high blood pressure at the age of 38, which motives her to try to live a healthy lifestyle to avoid high blood pressure. Her father has been diagnosed with a cataract of the eyes, which he is yet to perform surgery to remove the cataract, and her siblings have no significant health problems. Her mental health states she is stressed, and she stated schoolwork and trying to take care of her immediate familys day-to-day activities was putting a lot of stress on her because she has two children. Reason for Care Mrs. R.K.B stated, she started her menstrual cycle at the age of 13, which is an ideal age. Her last menstruation was on September 19th, 2020. She states her period is every 24 days, and she had never had a rectal exami2 Medical Health History Name Institutional Affiliation Professor Course Date Demographics Name: N/A. Gender: Female. Age: 20s. Race/Ethnicity: Caucasian/White. Occupation: Student Nurse. Education level: The patient is in the final year of her undergraduate nursing degree studies. Primary language: English. Nutrition: normal weight. Blood Pressure: Normal. Reason for visit: Annual check-up. Generally, the patient is awake, alert, and lively. The patient has no allergies to most drugs except NSAIDS, which causes her nosebleeds. Also, she has no reactions to foods and most additives. She has no signs of acute distress or any mental condition. The patient indicated she had her last annual medical check-up in January 2020. She came seeking another check-up just to make sure her health is fine and stable. Perception of Health Being a nursing student in her final year of study, the patient understands what good health is and has a positive attitude towards a healthy lifestyle. The patient understands the importance of check-ups and believes it is not good to ignore them even when generally feeling okay. The patient indicated that she follows a daily exercise routine to keep her body fit and boost her health and immunity. Although the patient is in normal weight, she has been dieting whenever she feels like her weight could be increasing. She eats three light meals on an average day and two when dieting. The patient does not use caffeinated substances, tobacco, alcohol or drugs, and avoids frequent red meat consumption. The patient stated that she uses contraceptives to prevent pregnancy since she is sexually active. However, she did not provide specific information about the contraceptives she uses. The patient demonstrated signs of eyesight complications since she frequently experiences a headache when studying in a poorly lit room. Past Medical History The patient indicated that she contracted chickenpox in childhood before she was immunized against the disease in the year 2000. Chickenpox is a common infection caused by the virus varicella-zoster. The infection manifests in small, fluid-filled blisters on the skin that causes an itchy sensation on the patient. The disease also causes a light cough in some patients. The itching and blister rash usually appears between 10 and 21 days of exposure through close contact with an infected person or surface. The virus lasts for five to ten days on the victims body. While chickenpox is considered a mild disease, it can have serious effects and complications such as pneumonia, brain inflammation, bacterial infections on the skin and bloodstream, dehydration, and sometimes death. The patient was recently immunized against influenza, hepatitis, tetanus, and MMR. The patient had no history of other medical problems diagnosed by doctors before and had never had a surgery experience. Further, the patient stated that she had no blood transfusion or previous hospitalizations in her life.Original Date: Dates Revised: enter text. enter text. enter text. enter text. HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Initials: N/A Race/Ethnicity: Caucasian/White ☐M ☒ F Age 20s Occupation: Student Nurse Marital status: ☒ Single ☐ Partnered ☐ Married ☐ Separated ☐ Divorced ☐ Widowed Reason for visit: Annual check-up Perception of health:”I’m just here for a yearly check-up” Date of last physical exam: 6/11/2020 Source of information: Patient Reason for seeking care: yearly check-up Present health or history of present illness: P enter text. Q enter text. R enter text. S enter text. T enter text. PERSONAL HEALTH HISTORY/Past health Childhood illness: Measles Mumps Rubella Chickenpox Rheumatic Fever Polio Immunizations and dates: ☒Tetanus June 2016 ☐Pneumonia N/A ☒Hepatitis August 2020 ☒Chickenpox June 2000 ☒Influenza August 2020 ☒MMR Measles, Mumps, Rubella August 2020 List any medical problems that other doctors have diagnosed enter text. Surgeries Year Reason Hospital N/A N/A N/A enter text. enter text. enter text. enter text. enter text. enter text. Other hospitalizations Year Reason Hospital enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. Have you ever had a blood transfusion? ☐ Yes ☒ No Please turn to next page List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers Name the Drug Strength Frequency Taken and Reason Cryselle N/A Every day; Birth Control enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. Allergies to medications, latex, food, iodine/betadine Name the Drug Reaction You Had NSAIDS Nose bleed enter text. enter text. enter text. enter text. HEALTH HABITS AND PERSONAL SAFETY All questions contained in this questionnaire are optional and will be kept strictly confidential. Exercise ☐Sedentary (No exercise) ☐Mild exercise (i.e., climb stairs, walk 3 blocks, golf) ☒Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) ☐Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes) Diet Are you dieting? ☐ Yes ☒ No If yes, are you on a physician prescribed medical diet? ☐ Yes ☒ No # of meals you eat in an average day? 2 meals Rank salt intake ☒Hi ☐Med enter text.Low Rank fat intake ☐Hi ☐Med