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NR304 RUA Health History and Physical Assessment

Health Assessment II (Chamberlain University)

Studocu is not sponsored or endorsed by any college or university

NR304 RUA Health History and Physical Assessment

Health Assessment II (Chamberlain University)

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RUA Health History and Physical Assessment

Alexandra Blackwood

Chamberlain University College of Nursing

NR304: Health Assessment II

Professor Rodgers

April 03, 2022

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RUA Health History and Physical Assessment

Health History: Subjective Data

P.B. is a 56-year-old African American male born March in Jamaica and currently resided

in New York. His primary language is English. He is 6-foot 1 inch and currently weighs 280

pounds. His marital status is married. His reason for seeking care is a routine yearly check-up.

P.B. has no present illness. P.B. defines health as the presence and absence of an illness or

condition. He considers himself to be healthy. He does participate in tobacco, he smokes about 5

cigarettes a day, and drink alcohol three times a week but does not use illicit drugs. All P.B.’s

childhood vaccinations are up to date. Received his Covid-19 vaccine in June 2021. His last flu

shot was in October 2021. He stated no known past medical history or surgical history. P.B.

states no known allergies. He does not currently take any medication. From the information he

has can recall father passed away from cancer in 2019, mother passed away from dementia in

2018. P.B. states no presence of skin cancer, itching, rashes, or bruising. He expresses no

presence of headaches or head injuries. He voices never wearing glasses or contacts and has not

experienced any change in vision or eye pain. He declares no ringing in the ears, colds, or sore

throat. He states no wheezing, cough, or shortness of breath. He affirms no pacemaker, irregular

rhythm, or murmurs. P.B. denies any clot in veins, leg cramps, or varicose veins. He states no

change in appetite, constipation, or rectal bleeding. He expresses no pain or burning on urination,

difficulty urinating, or incontinence. He denies any presence of seizures, weakness, or strokes.

He makes known that he does experience pain and stiffness in his knee in the colder months but

no fractures. He discloses that his last prostate exam was in May 2021.

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P.B. is currently at the Generativity vs. Stagnation stage of his life in Erikson’s stages of

psychosocial development. This stage refers to making your mark. At this stage, individuals

experience the need to nurture things that will survive them, creating a change that will benefit

others. He reveals that a tradition his family continues to follow is when they experience any

illness come along, they would take a shot of rum with honey in hopes that it would reduce or rid

the symptoms. Family plays a crucial part in shaping him into the person he is today. He

describes himself as a family-oriented person. He does not belong to a religious organization but

does have spiritual belief that there is a greater entity.

Physical Examination: Objective Data

In his physical assessment, his oral temperature is 98.6°F (37 C), his heart rate is 80 beats

per minute, and is regular, his respirations are 20. Blood pressure is 130/64 which indicates pre-

hypertension. His O2 saturation is 98%. He states his pain is a 0 on a 0-10 pain scale. P.B.’s head

is normocephalic and free of any lesions or infestations. For his eyes, his conjunctiva is pink and

moist, sclera is white and moist. His pupil size is 3 mm and equal, they are round, reactive to

light, and accommodate. There is no presence of discharge in his ears. Whisper test was passed.

P.B.’s nose is symmetrical, there are no deformities, inflammation, drainage, and bilateral

patency is present. His thyroid and chain of lymph nodes are nonpalpable and not tender. P.B.’s

throat is moist. His cardiovascular system functions are normal. His heartbeat is regular no

murmurs are present. There is no presence of edema. His respiratory system is intact. He does

not complain of any shortness of breath. There is an absence of wheezing. Lungs sounds are

clear anterior and posterior. No accessory muscle usage. P.B. is alert and oriented to person,

place, time, and situation. P.B.’s abdomen is slightly rounded and symmetrical. His bowel sounds

are normal within each quadrant. He shows no signs of guarding or rigidity. No tenderness or

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distention is present. His upper and lower extremities have ROM and muscle strength is 4 out of

5. Gait is steady and balanced. His peripheral system is within normal limits. All cranial nerves

are intact.

Needs Assessment

Educating patients on their health needs is essential to create awareness for preventing

and managing conditions. Pertaining to his health history and physical exam, he is a well-

functioning individual with exception of being pre-hypertensive. In order to improve and

maintain his health status, I would recommend limiting his alcohol intake and stopping smoking.

According to Mostofsky et al. (2016) heavy alcohol consumption has been linked to

hypertension.

When it comes to his smoking habits, despite having no complications with his lungs, it

can influence his respiratory system. As stated by Tantisuwat and Thaveeratitham (2014),

smoking decreases pulmonary function including forced vital capacity. Reduced vital capacity

can be associated with weak cough, atelectasis, and hypoxemia. This can interfere with heart and

brain functions.

A crucial element that will ensure the success of health promotion is collaborating with

family and friends. Their family and friends will encourage the importance of living a healthy

lifestyle. They can support them emotionally and financially. It also provides access to resources

to gain some knowledge and refresh the key information they have received.

Reflection

My interaction with the patient was pleasant. I have made sure I had a comfortable

approach and environment. I utilized the techniques I learned in Health Assessment I and II. I did

not experience any barriers. I am grateful I had the tools necessary to get the information I

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needed for the physical assessment. What went well was I was able to implement what I learned

outside of class. There were no unanticipated challenges during this assignment. Some

information I wish was available was more details on his family history regarding immediate

family. He did not have information on his grandparents. To alter my approach next time, I will

give the patient enough time to gather information on medical history as well as family history.

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References

Mostofsky, E., Mukamal, K. J., Giovannucci, E. L., Stampfer, M. J., & Rimm, E. B. (2016). Key

Findings on Alcohol Consumption and a Variety of Health Outcomes From the Nurses’

Health Study. American journal of public health, 106(9), 1586–1591.

https://doi.org/10.2105/AJPH.2016.303336

Tantisuwat, A., & Thaveeratitham, P. (2014). Effects of smoking on chest expansion, lung

function, and respiratory muscle strength of youths. Journal of physical therapy science,

26(2), 167–170. https://doi.org/10.1589/jpts.26.167

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