Individual Health Assessment Essay

Client/ forbearing Initials DN Sex M Age 66 business sector of Client/Patient RetiredHealth History/Review of arrangings(Complete and systematic review of systems) Neurological agreement ( directaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications)No complaints of headaches, no capitulumly(prenominal) head injuries, no complaints of dizziness, no history of convulsion, tremors or weakness. The diligent of of states he has had no numbness, tingling, or unsteady gait. The unhurried denies dysphagia or dysphasia. Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/ s hygienicing, surgeries on head/neck, medications)The unhurried denies head pain, head or neck injury or trauma, no nodules or surgeries. The longanimous denies winning medication for head or neck. Eyes (eye pain, blurred vision, history of crossed eyes, excitation/swelling in eyes, watering, tearing, i njury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications)The unhurried does wear corrective glasses.The affected role denies redness or swelling in eyes nor watering. The diligent role denies history of eye injury or surgery. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications)The patient denies ear pain or new ear infections. The patient does have a bandage to right ear stating he just had scratch cancer removed. Incision intact. No surrounding redness or swelling. The patient denies drain. The patient denies vertigo. Nose, Mouth, and pharynx (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental c atomic number 18, medications)The patient denies sore throat, runny nose, or sores to mouth. The patient has saddentition and states he sees a dentist regularly.The patient st ates he brushes his teeth twice daily. The patient denies seasonal allergies. Skin, Hair and Nails (skin disease, changes in affectation, changes in a mole, luxuriant dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications)The patient denies excessive dryness or excessive moisture to skin. The patient states history of skin cancer. The patient states he has had several spots removed for skin cancer including his nose, right ear, and cheek. The patient denies bruising easily. Breasts and Axilla (pain or marrow, lumps, boob 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. computer peripheral Vascular and lymphatic System (leg pain, cramps, skin changes in arms or legs, 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 System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications)The patient states he has a history of heart attack and high blood 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, smoking history, living/working conditions that affect breathing, hold 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 lung 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 limitation of movement muscleman pain or cramping deformity 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 not tolerated abdominal pain nausea or emetic frequency of BM history of GI disease, ulcers, medications)The patient denies changes in appetite. The patient denies difficulty swallowing. The patient denies foods that are 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 region 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. take findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments)Cranial organization I Sense of smell intact evidenced by smelling an onion as well as cinnamon with eyes closed. Cranial Nerve II Snellen eye chart eye exam exhibitor 20/40 in bilateral eyes without corrective lenses. Patient is 20/20 in bilateral eyes with corrective le nses. Cranial Nerve II, IV, and VI Pupils mate, round, and reactive to light and accommodation. Extraocular movements are within recipe limits. Cranial Nerve V Mastication muscles are equal bilaterally. Cranial Nerve vii Facial symmetry renowned. Facial nerves function appears within normal limits. Cranial Nerve VIII Normal hearing functioned noted with hearing loopy spoken words as well as normal conversation. Cranial Nerve IX and X The patient has a positive gag innate reflex as well as normal appearing uvula and soft palate. Cranial Nerve XI The sternocleidomastoid and trapezius muscles are symmetric. Neck and head with oerflowing range of gesture. 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 abnormalities of tongue noted. Head and Neck ( sense the skull, take stock the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpa te and auscultate the thyroid gland) reflexion is symmetric.Trachea is midline. Lymph nodes within normal limits with nogoiter noted. The patient has dependable range of motion to head and neck. The patients head is without nodules noted. The patient has ironlike carotid twinklings present bilaterally. Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external 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 hearing 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 pearly gray with normal light reflex. No perforations noted. Ear canal redundant 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. Nasal 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, but 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, teach 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 odd 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 upper 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 heave or lift, top(prenominal) impulse auscultate rate and rhythm identify S1 and S2, any extra heart sounds, murmur)Th e 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, tactile fremitus, trachea palpate symmetrical expansion, percussion of anterior, lateral and posterior, abnormal breathing sounds)The patients chest has equal and bilateral rise 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 posterior 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 shoulders 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 near range of motion. The patients elbows are free 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 masses or deformities noted. The patient denies pain to knees. The patients knees are symmetric without obvious masses. 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, rebound 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 sampleThe patient has no cognitive defects noted. Nutritional-Metabolic PatternThe 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 urination. 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 sta tes 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 format that provides logical progression of assessment.) stead (reason for seeking care, patient statements)The patient presents today 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 patient states his mother passed away from lung cancer and his scram with brain cancer. The patient denies drainage or surrounding redness to area. The patient states he applied antibiotic oin tment 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. Nursing Diagnosis Risk for infection related to incision to right ear (Gulanick & Myers, 2007). Recommendation (diagnostic evaluation, follow-up care, patient education article of faith including health promotion education)The patient needs to continue to apply 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 skills as well as signs of fever or illness. The patient is also educated on the greatness of follow up with his dermatologist. ******ReferencesGulanick, M., & Myers, J. (2007). Nursing ca re plans Diagnosis, interventions, and outcomes. (6th ed.). St. Louis, Missouri Elsevier Mosby.Jarvis, C. (2012). Physical Examination & Health Assessment (6th ed.). St. Louis, Missouri Elsevier Saunders.