Individual Health Assessment Essay

Client/Patient Initials DN Sex M epoch 66 Occupation of Client/Patient Re ejectdHealth History/ round off of dusts(Complete and systematic review of systems) Neurological body ( topicaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, fuss speaking, bother swallowing, etc., medications)No complaints of headaches, no past head injuries, no complaints of dizziness, no accounting of convulsion, tremors or weakness. The tolerant states he has had no numbness, tingling, or unsteady gait. The longanimous denies dysphagia or dysphasia. honcho and Neck ( trouble oneself, headaches, head/neck dent, neck bother, lumps/ projection, surgeries on head/neck, medications)The uncomplaining denies head nuisance, head or neck injury or trauma, no nodules or surgeries. The longanimous denies taking medication for head or neck. Eyes ( fondness annoyance, blurred vision, score of crossed look, inflammation/swelling in eye, watering, t auricleing, inj ury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications)The tolerant does w pinnule corrective glasses.The persevering denies redness or swelling in eyes nor watering. The unhurried denies history of eye injury or surgery. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, bother hearing, environmental noise exposure, vertigo, medications)The diligent denies ear pain or novel ear infections. The affected role does have a bandage to right ear stating he just had fell malignant neoplastic disease removed. Incision intact. No surrounding redness or swelling. The tolerant denies drainage. The forbearing denies vertigo. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental c atomic number 18, medications)The forbearing role denies sore throat, runny nose, or sores to mouth. The long-suffering has poordentition and s tates he sees a dentist regularly.The uncomplaining states he brushes his teeth tw scratch daily. The forbearing denies seasonal allergies. Skin, bullsbreadth and Nails ( scrape up disease, changes in color, changes in a mole, undue dryness or moisture, itching, bruising, roseola or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications)The patient denies excessive dryness or excessive moisture to struggle. The patient states history of skin cancer. The patient states he has had some(prenominal) spots removed for skin cancer including his nose, right ear, and cheek. The patient denies bruising easily. Breasts and Axilla (pain or union, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications)The patient denies pain or tenderness to breasts. The patient denies rash or swelling to breasts. Peripheral Vascular and lymphatic system of rules (leg pain, cramps, skin changes in arms or le gs, swelling in legs or ankles, swollen glands, medications)The patient denies leg pain or cramping. The patient denies swelling in lower extremities and denies taking medications to increase circulation. Cardiovascular constitution (chest pain or tightness, SOB, cough, swelling of feet or custody, family history of cardiac disease, tire easily, self-history of heart disease, medications)The patient states he has a history of heart storm and high blood atmospheric pressure. The patient denies shortness of breath or recent chest pain. The patient states he currently takes Coreg and Aspirin daily. Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, take history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications)The patient denies cough or shortness of breath. The patient denies chest pain upon inspiration or expiration.The patient denies l ung disease. The patient states he stopped smoking 32 years ago. The patient states he is up to date on his flu vaccination as well as his pneumonia vaccination. Musculoskeletal System (joint pain stiffness swelling, heat, redness in joints demarcation line of movement muscle pain or cramping defacement of bone or joint accidents or trauma to bones back pain difficulty with activity of daily living, medications)The patient denies joint pain or stiffness. The patient denies muscle pain or cramping. The patient denies deformity of bones or joint. The patient denies history of trauma or accident to bones or muscle. The patientdenies debilitation to activities of daily living. Gastrointestinal System (change in appetite increase or loss difficulty swallowing foods non tole outrankd abdominal pain nausea or vomiting frequency of BM history of GI disease, ulcers, medications)The patient denies changes in appetite. The patient denies difficulty swallowing. The patient denies foods t hat be not tolerated. The patient denies frequent nausea or vomiting. The patient states he has a regular bowel movement daily. The patient denies history of GI ulcers or taking medications for GERD or acid reflux. Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, suprapubic sh atomic number 18 or low back)The patient denies urgency, frequency, or dysuria. The patient denies polyuria.The patient states history of kidney stones. The patient denies incontinence or flank pain. The patient denies groin pain or low back pain. Physical Examination(Comprehensive examination of each system. remember findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory(prenominal) assessments)Cranial fount I Sense of smell intact evidence by smelling an onion as well as cinnamon bark with eyes closed. Cranial Nerve II Snellen eye chart eye exam shower 20/40 in bilateral eyes without corrective lenses. Patient is 20/20 in bilateral eyes with corrective lenses. Cranial Nerve II, IV, and VI Pupils extend to, round, and reactive to igniter and accommodation. Extraocular movements are at bottom rule limits. Cranial Nerve V Mastication muscles are equal bilaterally. Cranial Nerve VII facial symmetry tell. Facial nerves function appears deep down normal limits. Cranial Nerve ogdoad Normal hearing functioned noted with hearing soft spoken words as well as normal conversation. Cranial Nerve IX and X The patient has a positive gag reflex as well as normal appearing uvula and soft palate. Cranial Nerve XI The sternocleidomastoid and trapezius muscles are biradial. Neck and head with intact wave of crusade. Shoulder shrug showing trapezius muscle equal bilaterally. Cranial Nerve XII The patients speech is within normal limits with a midline tongue. No sores, lesions, or kinkyit ies of tongue noted. Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland)Face is symmetric.Trachea is midline. Lymph nodes within normal limits with no scrofula noted. The patient has unspoilt range of motility to head and neck. The patients head is without nodules noted. The patient has strong carotid pulses present bilaterally. Eyes (test optical acuity, visual fields, extraocular muscle function, inspect outer eye structures, inspect anterior eyeball structures, inspect ocular fundus) Patient is 20/20 in bilateral eyes with corrective lenses. Extraocular movements are intact. No nystagimus or strabismus noted. Pupils are equal, round, and reactive to light and accommodation. No drainage or redness noted to bilateral eyes. Conjunctiva are pink, sclera white without redness noted. Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test hea ring acuity)The patients ears are symmetric. The patient has a dressing to right ear from recent skin cancer removal. Incision clear without redness or drainage. The patients hearing within normal limits. Bilateral tympanic membranes intact and eggbeater gray with normal light reflex. No perforations noted. Ear canal impoverished of drainage. Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat)The patients nose is symmetric with no nasal drainage noted. wasted septum midline. The patient denies tenderness of the external nares. Nasal mucosa is pink and within normal limits. Nares patent. No nasal flaring noted. Mouth within normal limits with no sores or blisters noted to tongue. Tongue is midline. Tonsils are pink with no swelling noted. The patient has no dental caries noted, besides several fillings noted. Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, educate self-examination techniques)The patients skin with no dryness, rashes, or acne noted.The patient has a scar noted to his nose, right ear, and left cheek. The patient states this is areas of skin cancer that have been removed. Skin turgor within normal limits with no tenting. The patients hair is thin with no signs of dandruff. The patients nails are not brittle. No clubbing noted. Capillary refill is less than three seconds. Breasts and Axilla (deferred for purpose of class assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps)The patient has no swelling noted to f number or lower extremities. Skin color within normal limits with no discoloration. Peripheral pulses arestrong and equal bilaterally. The patients legs are without varicosities. Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium soar up or lift, apical impulse auscultate rate and rhythm get word S1 and S2, any extra heart toilsomes, murmur)The patients blood pressure is 128/78, pulse 68. Upon auscultation, the apical pulse is also 68 with regular rate and rhythm. No murmur or arrhythmia noted. S1 and S2 noted without murmur. No bruit noted.No jugular vein distention noted. Thorax and Lungs (inspect thoracic cage, symmetry, haptic fremitus, trachea palpate symmetrical expansion, percussion of anterior, lateral and lowlife, abnormal breathing sounds)The patients chest has equal and bilateral rebel and fall with good muscle tone. The patient denies chest tenderness upon palpation. respiratory rate 17 breaths per minute and regular. Tactile fremitus symmetrical over smudgeerior lung area of the back. Lungs sounds clear in all four lobes. Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion inspect shoulder s for size, color, contour, swelling, mass, deformity, pain, range of motion inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion inspect hips for size, color, contour, swelling, mass, deformity, pain, range of motion inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion)The patient has no curvature noted to spine. The spine is without swelling or deformity. The patient denies cervical tenderness or pain. The patients shoulders are symmetric with full range of motion. The patients elbows are acquit of deformity with full range of motion. The patient denies pain to elbows. The patients wrist are free of deformity with full range of motion. The patient denies pain to wrists. The patients hands are free of deformity with full range of motion. The patient denies pain to hands. The patient has healed scars from bilateral carpal tunnel surgery. The patients hips are symmetric with full range of motion.The patient denies pain to hips. The patients knees are symmetric with full range of motion. No crowd together or deformities noted. The patient denies pain to knees. The patients knees are symmetric without obvious battalion. The patient has full range of motion to bilateralknees. The patient denies pain to bilateral knees. The patients feet are without swelling. The patient has full range of motion to ankle and foot. No obvious deformities or masses noted. Skin is intact to bilateral feet. (Jarvis, 2012). Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution auscultate bowel sound, percuss all four quadrants percuss border of liver light palpation in all four quadrants muscle wall, tenderness, enlarged organs, masses, rag tenderness, CVA tenderness)The patients abdomen is symmetric, soft, and round. The patient has normal hair distribution with skin pink. The patient denies tenderness to all four quadrants. bowel sounds normoactive x4 quadrants. No masses palpated. Liver palpates within normal limits. Genitourinary System (deferred for purpose of this class) FHP AssessmentCognitive-Perceptual exemplarThe patient has no cognitive defects noted. Nutritional-Metabolic anatomyThe patient states he eats breakfast, lunch, and dinner. The patient states he tries to watch what he eats. He does however state he has a weakness for ice cream. Sexuality-Reproductive PatternThe patient states he has been married to his wife for 28 years. He denies problems or issues with his sex life and states he is satisfied. Pattern of EliminationThe patient states he has a regular bowel movement daily. The patient denies problems with diarrhea or constipation. The patient denies any problems with urinatio n. The patient denies waking at night to urinate. Pattern of Activity and ExerciseThe patient states since retirement, he has slacked on his daily exercise. The patient states the only exercise he gets is daily yard work and gardening. The patient states he used to take a mile long walk, but has slacked off of that. Pattern of Sleep and RestThe patient states he gets 7 hours of sleep nightly.The patient denies waking throughout the night. Pattern of Self-Perception and Self-ConceptThe patient presents as a confident male who has continuous eye contact. Summarize Your Findings(Use data formatting that provides logical progression of assessment.) Situation (reason for seeking care, patient statements)The patient presents instantly for a recheck of his healing incision to right ear status post removal of skin cancer. Background (health and family history, recent observations)The patientstates he has a history of several skin cancer spots that have been previously removed. The pa tient states his mother passed away from lung cancer and his father with brain cancer. The patient denies drainage or surrounding redness to area. The patient states he utilise antibiotic ointment as well as a dressing twice daily. Assessment (assessment of health state or problems, nursing diagnosis)The patient has a healing incision noted to right ear. This incision is free of drainage or redness. nurse Diagnosis Risk for infection link to incision to right ear (Gulanick & Myers, 2007). Recommendation (diagnostic evaluation, follow-up care, patient training teaching including health promotion education)The patient needs to continue to hold back the antibiotic ointment as well as dressing to the ear twice daily. The patient needs to continue to observe the area for drainage, redness, or signs of infection. The patient needs to continue to inspect his skin for areas that may be suspicious for additional skin cancer lesions. The patient is educated on proper hand-washing skill s as well as signs of fever or illness. The patient is also educated on the importance of follow up with his dermatologist. ******ReferencesGulanick, M., & Myers, J. (2007). Nursing care plans Diagnosis, interventions, and outcomes. (6th ed.). St. Louis, molybdenum Elsevier Mosby.Jarvis, C. (2012). Physical Examination & Health Assessment (6th ed.). St. Louis, Missouri Elsevier Saunders.