HEALTH ASSESSMENT
Home>Homework Answsers>Nursing homework helpnursing2 years ago12.10.20231Report issuefiles (1)PhysicalAssessmentHealthHistoryform1.docxPhysicalAssessmentHealthHistoryform1.docxNUR2092 WRITE-UP—HEALTH HISTORY
Classroom Assignment Week TwoDate __________________________ Examiner ______________________1. Biographic Data Name_______________________________________________ Phone________________________ Address____________________________________________________________________________ Birthdate ________________________________ Birthplace _________________________________ Age __________ Gender __________ Marital Status ______________ Occupation _______________ Race/ethnic origin __________________________________ Employer ________________________2. Source and Reliability3. Reason for Seeking Care4.Present Health or History of Present IllnessPast Health HistoryDescribe general health ______________________________________________________________ Childhood illnesses __________________________________________________________________ Accidents or injuries (include age) ______________________________________________________ Serious or chronic illnesses (include age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (name procedure, age) ______________________________________________________
Obstetric history: Gravida ____________ Term ____________ Preterm ____________ (# Pregnancies)
(# Term pregnancies) (# Preterm pregnancies)
Ab/incomplete _____________________ Children living _____________________ (# Abortions or miscarriages) _____Course of pregnancy__________________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition)
Immunizations_____________________________________________________________________Last examination date:Physical ________________Dental ________________ Vision ________________Allergies_________________________________ Reaction __________________________________Current medications _________________________________________________________________ _6. Family History—Specify Which Relative(s)Heart disease___________________________ High blood pressure______________________ Stroke_________________________________ Diabetes_______________________________Blood disorders_________________________ Breast or ovarian cancer___________________Cancer (other)__________________________ Sickle cell______________________________ Arthritis_______________________________
Allergies_______________________________ Asthma _______________________________ Obesity________________________________ Alcoholism or drug addiction ______________Mental illness ___________________________ Suicide ________________________________Seizure disorder ________________________ Kidney disease __________________________ Tuberculosis _____Review of Systems (Circle/highlight both past health problems that have been resolved and current problems, including date of onset.)General Overall Health State:Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweatsSkin:History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesionHair:Recent loss, change in textureNails:Change in shape, color, or brittlenessHealth Promotion:Amount of sun exposure, method of self-care for skin and hairHead:Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigoEyes:Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataractsHealth Promotion Eyes:Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if anyEars:Earaches, infections, discharge and its characteristics, tinnitus, or vertigoHealth Promotion Ears:Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning earsNose and Sinuses:Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smellMouth and Throat:Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered tasteHealth Promotion/Mouth & Throat:Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkupNeck:Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiterBreast:Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rashHealth Promotion Breast:Performs breast self-examination, including frequency and method used, last mammogram and resultsRespiratory System:History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposureHealth Promotion Respiratory: Last chest x-ray examinationCardiovascular System:Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemiaHealth Promotion Cardiovascular:Date of last ECG or other heart tests and resultsPeripheral Vascular System:Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcersHealth Promotion Peripheral Vascular: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose.Gastrointestinal System:Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula)Health Promotion Gastrointestinal:Use of antacids or laxativesUrinary System:Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low backHealth Promotion Urinary:Measures to avoid or treat urinary tract infections, use of Kegel exercisesMale Genital System:Penis or testicular pain, sores or lesions, penile discharge, lumps, herniaHealth Promotion Male Genital:Perform testicular self-examination? How frequently?Female Genital System:Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.Health Promotion Female Genital:Last gynecologic checkup, last Pap test and resultsSexual Health:Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis)?Musculoskeletal System:History of arthritis or gout. In the joints: pain, stiff-ness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait prob-lems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.Health Promotion Musculoskeletal:How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?Neurologic System:History of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.Hematologic System:Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.Endocrine System:History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy.Functional Assessment (Including Activities of Daily Living)Self-Esteem, Self-Concept: Education (last grade completed, other significant training) ______________Financial status(income adequate for lifestyle and/or health concerns) __________Value-belief system(religious practices and perception of personal strengths) ___________Self-care behaviors______________________Activity and Exercise:Daily profile, usual pattern of a typical day ________________________________Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs_________________________________Leisure activities________________________________________Exercise pattern(type, amount per day or week, method of warm-up session, method of monitoringSleep and Rest: Sleep patterns, daytime naps, any sleep aids used___________________Nutrition and Elimination: Record 24-hour diet recall._______________________________________ _____________________________________________________________________________________Is this menu pattern typical of most days?___________________________________________________Who buys food?____________________________Who prepares food?__________________________Finances adequate for food?__________________________________Who is present at mealtimes?__________________________________Interpersonal Relationships and Resources: Describe own role in family_________________________How getting along with family, friends, co-workers, classmates______________________Get support with a problem from?______________________________________________How much daily time spent alone?_______________________________________________________Is this pleasurable or isolating?___________________________________________________________Coping and Stress Management: Describe stresses in life now__________________________________ _____________________________________________________________________________________Change(s) in past year______________________________________________Methods used to relieve stress_______________________Are these methods helpful?___________________________Personal Habits:Daily intake caffeine (coffee, tea, colas)______________________________________Smoke cigarettes?____________________________Number packs per day______________Daily use for how many years__________________Age started___________Ever tried to quit?____________________________How did it go?_____________________________Drink alcohol? ____________________ Date of last alcohol use_______Amount of alcoholthat episode__________________________________________________________Out of last 30 days, on how many days had alcohol?____________________________________Ever told had a drinking problem?________________________________________________________Any use of street drugs?___________Marijuana?_________________________________Cocaine?__________________________________Crack cocaine?______________________________Amphetamines?_____________________________Heroin?__________________Prescription painkillers?_____________________Barbiturates?_______________________________LSD?_____________________________________Ever been in treatment for drugs or alcohol?________________________________________________Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors)_____________________________________________________________________________________Safety of area_________________________________________________________________________Adequate heat and utilities____________________________________________________________Access to transportation____________________________________________________________Involvement in community services_______________________________________________________Hazards at workplace or home___________________________________________________________Use of seatbelts____________________________________________________________________Travel to or residence in other countries___________________________________________________Military service in other countries________________________________________________________Self-care behaviors_____________________________________________________________________Intimate Partner Violence: How are things at home? Do you feel safe? __________________Ever been emotionally or physically abused by your partner or someone important to you___-Ever been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner?_____________________________________________________________________________________Partner ever force you into having sex?____________________________________________________Are you afraid of your partner or ex-partner?________________________________Occupational Health:Please describe your job.______________________________________________Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)?___________________________________________________________________________________Any equipment at work designed to reduce your exposure?Any work programs designed to monitor your exposure?_________________________________Any health problems that you think are related to your job?_____________________________What do you like or dislike about your job?_________________________________________________Perception of Own Health:How do you define health?________________________________________View of own health now________________________________________________________________What are your concerns?________________________________________________________________What do you expect will happen to your health in future?_______________________Your health goals______________________________________________________________________Your expectations of nurses, physicians___________________________________________________PhysicalAssessmentHealthHistoryform1.docxNUR2092 WRITE-UP—HEALTH HISTORY
Classroom Assignment Week TwoDate __________________________ Examiner ______________________1. Biographic Data Name_______________________________________________ Phone________________________ Address____________________________________________________________________________ Birthdate ________________________________ Birthplace _________________________________ Age __________ Gender __________ Marital Status ______________ Occupation _______________ Race/ethnic origin __________________________________ Employer ________________________2. Source and Reliability3. Reason for Seeking Care4.Present Health or History of Present IllnessPast Health HistoryDescribe general health ______________________________________________________________ Childhood illnesses __________________________________________________________________ Accidents or injuries (include age) ______________________________________________________ Serious or chronic illnesses (include age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (name procedure, age) ______________________________________________________
Obstetric history: Gravida ____________ Term ____________ Preterm ____________ (# Pregnancies)
(# Term pregnancies) (# Preterm pregnancies)
Ab/incomplete _____________________ Children living _____________________ (# Abortions or miscarriages) _____Course of pregnancy__________________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition)
Immunizations_____________________________________________________________________Last examination date:Physical ________________Dental ________________ Vision ________________Allergies_________________________________ Reaction __________________________________Current medications _________________________________________________________________ _6. Family History—Specify Which Relative(s)Heart disease___________________________ High blood pressure______________________ Stroke_________________________________ Diabetes_______________________________Blood disorders_________________________ Breast or ovarian cancer___________________Cancer (other)__________________________ Sickle cell______________________________ Arthritis_______________________________
Allergies_______________________________ Asthma _______________________________ Obesity________________________________ Alcoholism or drug addiction ______________Mental illness ___________________________ Suicide ________________________________Seizure disorder ________________________ Kidney disease __________________________ Tuberculosis _____Review of Systems (Circle/highlight both past health problems that have been resolved and current problems, including date of onset.)General Overall Health State:Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweatsSkin:History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesionHair:Recent loss, change in textureNails:Change in shape, color, or brittlenessHealth Promotion:Amount of sun exposure, method of self-care for skin and hairHead:Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigoEyes:Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataractsHealth Promotion Eyes:Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if anyEars:Earaches, infections, discharge and its characteristics, tinnitus, or vertigoHealth Promotion Ears:Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning earsNose and Sinuses:Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smellMouth and Throat:Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered tasteHealth Promotion/Mouth & Throat:Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkupNeck:Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiterBreast:Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rashHealth Promotion Breast:Performs breast self-examination, including frequency and method used, last mammogram and resultsRespiratory System:History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposureHealth Promotion Respiratory: Last chest x-ray examinationCardiovascular System:Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemiaHealth Promotion Cardiovascular:Date of last ECG or other heart tests and resultsPeripheral Vascular System:Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcersHealth Promotion Peripheral Vascular: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose.Gastrointestinal System:Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula)Health Promotion Gastrointestinal:Use of antacids or laxativesUrinary System:Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low backHealth Promotion Urinary:Measures to avoid or treat urinary tract infections, use of Kegel exercisesMale Genital System:Penis or testicular pain, sores or lesions, penile discharge, lumps, herniaHealth Promotion Male Genital:Perform testicular self-examination? How frequently?Female Genital System:Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.Health Promotion Female Genital:Last gynecologic checkup, last Pap test and resultsSexual Health:Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis)?Musculoskeletal System:History of arthritis or gout. In the joints: pain, stiff-ness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait prob-lems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.Health Promotion Musculoskeletal:How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?Neurologic System:History of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.Hematologic System:Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.Endocrine System:History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy.Functional Assessment (Including Activities of Daily Living)Self-Esteem, Self-Concept: Education (last grade completed, other significant training) ______________Financial status(income adequate for lifestyle and/or health concerns) __________Value-belief system(religious practices and perception of personal strengths) ___________Self-care behaviors______________________Activity and Exercise:Daily profile, usual pattern of a typical day ________________________________Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs_________________________________Leisure activities________________________________________Exercise pattern(type, amount per day or week, method of warm-up session, method of monitoringSleep and Rest: Sleep patterns, daytime naps, any sleep aids used___________________Nutrition and Elimination: Record 24-hour diet recall._______________________________________ _____________________________________________________________________________________Is this menu pattern typical of most days?___________________________________________________Who buys food?____________________________Who prepares food?__________________________Finances adequate for food?__________________________________Who is present at mealtimes?__________________________________Interpersonal Relationships and Resources: Describe own role in family_________________________How getting along with family, friends, co-workers, classmates______________________Get support with a problem from?______________________________________________How much daily time spent alone?_______________________________________________________Is this pleasurable or isolating?___________________________________________________________Coping and Stress Management: Describe stresses in life now__________________________________ _____________________________________________________________________________________Change(s) in past year______________________________________________Methods used to relieve stress_______________________Are these methods helpful?___________________________Personal Habits:Daily intake caffeine (coffee, tea, colas)______________________________________Smoke cigarettes?____________________________Number packs per day______________Daily use for how many years__________________Age started___________Ever tried to quit?____________________________How did it go?_____________________________Drink alcohol? ____________________ Date of last alcohol use_______Amount of alcoholthat episode__________________________________________________________Out of last 30 days, on how many days had alcohol?____________________________________Ever told had a drinking problem?________________________________________________________Any use of street drugs?___________Marijuana?_________________________________Cocaine?__________________________________Crack cocaine?______________________________Amphetamines?_____________________________Heroin?__________________Prescription painkillers?_____________________Barbiturates?_______________________________LSD?_____________________________________Ever been in treatment for drugs or alcohol?________________________________________________Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors)_____________________________________________________________________________________Safety of area_________________________________________________________________________Adequate heat and utilities____________________________________________________________Access to transportation____________________________________________________________Involvement in community services_______________________________________________________Hazards at workplace or home___________________________________________________________Use of seatbelts____________________________________________________________________Travel to or residence in other countries___________________________________________________Military service in other countries________________________________________________________Self-care behaviors_____________________________________________________________________Intimate Partner Violence: How are things at home? Do you feel safe? __________________Ever been emotionally or physically abused by your partner or someone important to you___-Ever been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner?_____________________________________________________________________________________Partner ever force you into having sex?____________________________________________________Are you afraid of your partner or ex-partner?________________________________Occupational Health:Please describe your job.______________________________________________Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)?___________________________________________________________________________________Any equipment at work designed to reduce your exposure?Any work programs designed to monitor your exposure?_________________________________Any health problems that you think are related to your job?_____________________________What do you like or dislike about your job?_________________________________________________Perception of Own Health:How do you define health?________________________________________View of own health now________________________________________________________________What are your concerns?________________________________________________________________What do you expect will happen to your health in future?_______________________Your health goals______________________________________________________________________Your expectations of nurses, physicians___________________________________________________Bids(47)Jahky BPROF_ALISTERDr. Freya WalkerMUSYOKIONES A+Dr CloverDemi_RoseSheryl HoganBrilliant GeekTop MalaikaAshley EllieProf Double RTopanswerssherry proffJudithTutorMadam MichelleDr. BeneveElprofessoriLarry KellyMaria the tutorAmanda SmithShow All Bidsother Questions(10)For Professor 2013 onlyLeadership and Management Papercriminal justiceFoundations of Accounting I
Accounting Project
Written by: Karen Pitsch
Davidâs Entertainment is a merchandising business. Their account balances as of November 30,…Write a 350-word response regarding the differences between the direct and indirect presentation of cash flows. Why does the Financial…Language barriers.AssignmentsTERM PAPER ON CREDIT RISKeveryman assignment in theatreACC 281 Week 3 Methods of Analysis
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