Category: Nursing

Explain the difference between the two types of diabetes

Your mouth contains thousands of bacteria. How can bacteria survive in your mouth when you are eating, drinking, and producing saliva throughout the day and these actions would ‘wash’ the bacteria away?

Health History and Examination

 

Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems

 

Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include relevant data for your client.

 

Student Name:

Date:

 

Client/Patient Initials:

Sex:

Age:

Occupation of Client/Patient:

Health History/Review of Systems

(Complete and systematic review of systems)

Neurological System
(headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):

 

 

Head and Neck
(pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications):

 

 

Eyes
(eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):

 

 

Ears
(earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):

 

 

Nose, Mouth, and Throat
(discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):

 

 

Skin, Hair and Nails
(skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications):

 

 

Breasts and Axilla
(pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):

 

Peripheral Vascular and Lymphatic System
(leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):

 

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):

 

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, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications):

 

Musculoskeletal System
(joint pain; stiffness; swelling, heat, redness in joints; limitation  of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications)
:

 

Gastrointestinal System
(change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications)
:

 

 

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)
:

 

 

Physical Examination

(Comprehensive examination of each system. Record findings.)

Neurological System
(exam of all 12 cranial nerves, motor and sensory assessments):

 

 

 

 

 

 

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):

 

 

 

 

Eyes
(test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus):

 

 

 

 

Ears
(inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity):

 

 

 

 

Nose, Mouth, and Throat
(Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat):

 

 

 

 

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):

 

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):

 

 

 

 

 

Cardiovascular System
(inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S
1
and S
2
, any extra heart sounds, murmur):

 

Thorax and Lungs
(inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds):

 

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):

 

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):

 

 

 

Genitourinary System (
deferred for purpose of this class
)

FHP Assessment

Cognitive-Perceptual Pattern:

 

 

 

Nutritional-Metabolic Pattern:

 

 

 

Sexuality-Reproductive Pattern:

 

 

Pattern of Elimination

 

 

Pattern of Activity and Exercise:

 

 

 

Pattern of Sleep and Rest:

 

 

 

Pattern of Self-Perception and Self-Concept:

 

 

 

 

 

Summarize Your Findings

(Use format that provides logical progression of assessment.)

Situation
(reason for seeking care, patient statements):

 

 

 

 

Background
(health and family history, recent observations):

 

 

 

 

 

Assessment
(assessment of health state or problems, nursing diagnosis):

 

 

 

 

 

Recommendation
(diagnostic evaluation, follow-up care, patient education teaching including health promotion education):

Consider your current work environment and your role as a member of the health care team. What can you do to encourage collaboration and demonstrate stewardship?

Functional Health Pattern Assessment (FHP)

Pattern of Health Perception and Health Management:

How does the person describe current health?

What does the person do to maintain health?

What does person know about links between lifestyle and health?

How big a problem is financing health care for this person?

Can this person report his/her medications and the reason for taking them?

If this person has allergies, what does he/she do to prevent/manage them?

What does the person know about medical problems in his/her family?

Have there been any important illnesses/injuries in this person’s life?

Nutritional-Metabolic Pattern:

Is this person well-nourished?

How does this person’s food intake compare with recommended food intake?

Does this person have any disease that affects nutritional/metabolic function?

Pattern of Elimination:

Are the person’s excretory functions within normal range?

Does the person have any disease of the digestive system, urinary system, or skin?

Pattern of Activity and Exercise:

How does this person describe his/her weekly pattern of:

Activity/Leisure?–Exercise/Recreation?

·         Does this person have any disease that affects his/her:

Cardio/Respiratory System?–Musculoskeletal System?

Cognitive/Perceptual Pattern:

Does this person have any sensory deficits? If yes, are they corrected?

Can this person express himself/herself clearly and logically?

What is this person’s level of education?

Does this person have any disease that affects mental or sensory functions?

If this person has pain, describe it and its causes.

Pattern of Sleep and Rest:

Describe this person’s sleep/wake cycle.

Does this person appear physically rested and relaxed?

Pattern of Self-Perception and Self-Concept:

Is there anything unusual about this person’s appearance?

Does this person seem comfortable with his/her appearance?

Describe this person’s feeling state.

Role-Relationship Pattern:

How does this person describe his/her various roles in life?

Has, or does this person presently have positive role models for these roles?

Which relationships are most important to this person at this time?

Is this person presently going through any changes in role or relationships? If yes, describe changes.

Sexuality – Reproductive Pattern:

Is this person satisfied with his/her situation related to sexuality?

Does this person have any disease/dysfunction of the reproductive system?

Is this person satisfied with his/her plans regarding children?

Pattern of Coping and Stress Tolerance:

How does this person cope with difficult situations/problems?

Do these coping mechanism/actions help or make things worse?

Has this person had any treatment for emotional distress?

Pattern of Value and Beliefs:

What principles did this person learn as a child that are still important to him/her?

Does this person identify with any social, religious, ethnic, regional, cultural, or other groups?

What support systems does this person currently have?

In this Individual Client Health History and Examination assignment, you will be completing a health assessment on an older adult. To complete this assignment, do the following:

ORDER A PLAGIARISM-FREE PAPER NOW

Perform a health history on an older adult. Students who do not work in an acute setting may “practice” these skills with a patient, community member, neighbor, friend, colleague, or loved one. (If an older individual is not available, you may choose a younger individual).

Complete a physical examination of the client using the “Health History and Examination” assignment resource. Use the “Functional Health Pattern Assessment” resource as a guideline to assist you in completing the template.

Document findings of complete physical examination in Situation-Background-Assessment-Recommendation (SBAR) format. Refer to the sample SBAR Template located on the National Nurse Leadership Council website at 
https://www.ihs.gov/nnlc/includes/themes/newihstheme/display_objects/documents/resources/SBARTEMPLATE.pdf
 as a guide.

Document the findings of the physical examination in the assessment worksheet.

Using the “Health History and Examination” assignment resource, provide the physical examination findings summary with planned interventions for the client. Include any community services in the interventions.

APA format is not required, but solid academic writing is expected. Individual Client Health History and Examination Assignment.

This Individual Client Health History and Examination Assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this Individual Client Health History and Examination Assignment assignment to Turnitin.

NRS-434VN-R-Functional-Health-Pattern-Assessment-Student.docx
 
NRS-434VN-R-IndividualHealthHistoryandExaminationAssignment-Student.docx
.

Individual Client Health History and Examination Assignment

Describe A Existing Manual Or Electronic System With Which You Are Familiar. This System Should Be In Use In A Healthcare Context To Support Health Care Administration Or Health Care Delivery.

Assignment description is attached below. should include a data flow diagrams  regarding how the data flows in the proposed system as show in the attachment. word count can be 2000.

Qualitative Study

Background of Study:

Identify the clinical problem and research problem that led to the study. What was not known about the clinical problem that, if understood, could be used to improve health care delivery or patient outcomes?This gap in knowledge is the research problem.

How did the author establish the significance of the study? In other words, why should the reader care about this study? Look for statements about human suffering, costs of treatment, or the number of people affected by the clinical problem.

Identify the purpose of the study. An author may clearly state the purpose of the study or may describe the purpose as the study goals, objectives, or aims.

List research questions that the study was designed to answer. If the author does not explicitly provide the questions, attempt to infer the questions from the answers.

Were the purpose and research questions related to the problem?

Method of Study:

Were qualitative methods appropriate to answer the research questions?

Did the author identify a specific perspective from which the study was developed? If so, what was it?

Did the author cite quantitative and qualitative studies relevant to the focus of the study? What other types of literature did the author include?

Are the references current? For qualitative studies, the author may have included studies older than the 5-year limit typically used for quantitative studies. Findings of older qualitative studies may be relevant to a qualitative study.

Did the author evaluate or indicate the weaknesses of the available studies?

Did the literature review include adequate information to build a logical argument?

When a researcher uses the grounded theory method of qualitative inquiry, the researcher may develop a framework or diagram as part of the findings of the study. Was a framework developed from the study findings?

 

Results of Study

What were the study findings?

What are the implications to nursing?

Explain how the findings contribute to nursing knowledge/science. Would this impact practice, education, administration, or all areas of nursing?

Ethical Considerations

Was the study approved by an Institutional Review Board?

Was patient privacy protected?

Were there ethical considerations regarding the treatment or lack of?

Conclusion

Emphasize the importance and congruity of the thesis statement.

Provide a logical wrap-up to bring the appraisal to completion and to leave a lasting impression and take-away points useful in nursing practice.

Incorporate a critical appraisal and a brief analysis of the utility and applicability of the findings to nursing practice.

Integrate a summary of the knowledge learned.

Use the practice problem and a quantitative, peer-reviewed research article you identified in the Topic 1 assignment to complete this assignment.

In a 1000-1,250 word essay, summarize the study, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study.

Refer to the resource “Research Critique Guidelines” for suggested headings and content for your paper.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

This Quantitative Research Critique Assignment is a follow up to research previously done, which includes a critique of the Quantitative  research articles used for that assignment( if approved to do assignment research articles wil be provided to you). This assignments details are listed on the “assignment requirements” page. Also attached is a guideline (research critique guidelines)as to how the paper should be laid out, This is assignment is due, and does require to be turned into “Turnitin” 20 percent or less similarity is required. Please be advised that this is a nursing research assignment.