Health Assessment form (Nursing), what is some good information for a person who have a lot of healt

Health Assessment form (Nursing), what is some good information for a person who have a lot of health issues? Individual Health Assessment Form

(40 points)

Objective: Conduct a General survey and a Health history on
a family member or friend (client) over the age of 65 (or someone with major
health problems if younger)

GENERAL SURVEY: (8 pts)

Physical Appearance/Hygiene (2 pts):

General appearance: Gender? Apparent age? Ethnic group?
Does client appear healthy? Note general color of skin and general
hygiene Is client well-groomed or disheveled?

Body Structure (2 pts):

Observe general stature Is height appropriate for apparent
age? Does the client appear well nourished, with weight appropriate for height?
Note the position or posture Is it comfortable and relaxed? Are there any
obvious deformities?

Body Movement (2 pts):

Observe the client’s movement Does the client walk with
ease? Is the gait balanced and smooth? Do there appear to be any limitations to
range of motion? Are there any involuntary movements? Are they using any
assistive devices?

Emotional/Mental Status and Behavior (2 pts):

Note the general expression of the client Is the client
alert? Do they appear well rested or tired? Does the client converse
appropriately? Is the behavior appropriate for situation? Is the dress
appropriate for the weather?

Following
the completion of the General Survey complete a Health History of your client
Using the interviewing techniques learned gather the following information Use
your textbook as your guide Document responses in each category below Your
assignment must have accurate spelling and grammar A response is required for
EACH item in EACH category Copy this document & record your responses in a
word document That way you can just add the information without retyping the
entire document Please reformat and delete things as appropriate (such as in
review of systems – delete opposite sex when discussing reproductive system)

Health History

Biographical data: (1 pt)

Initals:____________

Age: ________ Marital status: ____M _____ S
_____Sep ____Cohab

Birth date: _____________________ Number of dependents: ___________________

Educational level: ________________________ Gender: _____F _____ M _____Other

Occupation:
___________________________________¬¬¬¬_________________________

Ethnicity/nationality: _____________________ Health insurance ____Yes _____No

Source of history (who gave you the information)/reliability
(how reliable is that person):
_______________________________________________________________________

Present health history: (2 points)

Current medical conditions/chronic illnesses:

Current medications:

Medication/food/environmental allergies:

Past health history: (5 points)

Childhood illnesses: Ask about history of mumps, chickenpox,
rubella, ear infections, throat infections, pertussis, and asthma

Hospitalizations/Surgeries: Include reason for
hospitalization, year, and surgical procedures

Accidents/injuries: Include head injuries with loss of
consciousness, fractures, motor vehicle accidents, burns, and severe
lacerations

Major diseases or illnesses: Include heart problems, cancer,
seizures, and any significant adult illnesses

Immunizations (dates of known):

Tetanus _______
Diphtheria ________ Pertussis
________ Mumps ________

Rubella _______
Polio _____________ Hepatitis B
______ Influenza _______

Varicella ______
Other ____________________________________________

Recent travel/military services: Include travel within past
year and recent and past military service

Date of last examinations:

Physical examination _________ Vision ___________ Dental ___________

Family History (2 points)

Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any
major health issues, and, if indicated, cause and age of death (date of death,
if known) Include a genogram, if you wish

Review of Systems (12 points total) Be sure to address ALL
items specifically

General health status (1 pt): Ask about fatigue, pain,
unexplained fever, night sweats, weakness, problems sleeping, and unexplained
changes in weight

Integumentary (1 pt):

Skin: Ask about change in skin color/texture, excessive
bruising, itching, skin lesions, sores that do not heal, change in mole Do you
use sun screen? How much sun exposure do you experience?

Hair: Ask about changes in hair texture and recent hair
loss

Nails: Ask about changes in nail color and texture,
splitting, and cracking

HEENT (2 pts):

Head: Ask about headaches, recent head trauma, injury or
surgery, history of concussion, dizziness, and loss of consciousness

Neck: Ask about neck stiffness, neck pain, lymph node
enlargement, and swelling or mass in the neck

Eyes: Ask about change in vision, eye injury, itching,
excessive tearing, discharge, pain, floaters, halos around lights, flashing
lights, light sensitivity, and difficulty reading Do you use corrective lenses
(glasses or contact lenses)?

Ears: Ask about last hearing test, changes in hearing, ear
pain, drainage, vertigo, recurrent ear infections, ringing in ears, excessive
wax problems, use of hearing aids

Nose, Nasopharynx, Sinuses: Ask about nasal discharge,
frequent nosebleeds, nasal obstruction, snoring, postnasal drip, sneezing,
allergies, use of recreational drugs, change in smell, sinus pain, sinus
infections

Mouth/Oropharynx: Ask about sore throats, mouth sores,
bleeding gums, hoarseness, change voice quality, difficulty chewing or
swallowing, change in taste, dentures and bridges

Respiratory (1 pt):

Ask about frequent colds, pain with breathing, cough,
coughing up blood, shortness of breath, wheezing, night sweats, last chest
x-ray, PPD and results, and history of smoking

Cardiovascular (1 pt):

Ask about chest pain, palpitations, shortness of breath,
edema, coldness of extremities, color changes in hands and feet, hair loss on
legs, leg pain with activity, paresthesia, sores that do not heal, and EKG and
results

Breasts (1 pt): (Remember men have breasts too)

Ask about breast masses or lumps, pain, nipple discharge,
swelling, changes in appearance, cystic breast disease, breast cancer, breast
surgery, and reduction/enlargement Do you perform BSE (when and how)? Date of
last clinical breast examination, and mammograms and results

Gastrointestinal (1 pt):

Ask about changes in appetite, heartburn, gastroesophageal
reflux disease, pain, nausea/vomiting, vomiting blood, jaundice, change in
bowel habits, diarrhea, constipation, flatus, last fecal occult blood test and
colonoscopy and results

Genitourinary (1 pt):

Ask about pain on urination, burning, frequency, urgency,
incontinence, hesitancy, changes in urine stream, flank pain, excessive urinary
volume, decreased urinary volume, nocturia, and blood in urine

Female/male reproductive (1 pt):

Both: Ask about lesions, discharge, pain or masses, change
in sex drive, infertility problems, history of STDs, knowledge of STD
prevention, safe sex practices, and painful intercourse Are you current
involved in a sexual relationship? If yes, heterosexual, homosexual,, bisexual?
Number of sexual partners in the last 3 months Do you use birth control? If
yes, method(s) used

Female: Ask about menarche, description of cycle, LMP,
painful menses, excessive bleeding, irregular menses, bleeding between periods,
last Pap test and results, painful intercourse, pregnancies, live births,
miscarriages, and abortions

Male: Ask about prostate or scrotal problems, impotence or
sterility, satisfaction with sexual performance, frequency and technique for
TSE, and last prostate examination and results

Musculoskeletal (1 pt):

Ask about fractures, muscle pain, weakness, joint swelling,
joint pain, stiffness, limitations in mobility, back pain, loss of height, and
bone density scan and results

Neurological (1 pt):
Ask about pain, fainting, seizures, changes in cognition, changes in
memory, sensory deficits such as numbness, tingling and loss of sensation,
problems with gait, balance, and coordination, tremor, and spasm

Psychosocial Profile (5 points)

Health practices and beliefs/self-care activities: Ask about type and frequency of exercise,
type and frequency of self examination, oral hygiene practice (frequency of
brushing/flossing), screening examinations (blood pressure, prostate, breast,
glucose, etc)

Nutritional patterns: Ask about typical daily intake (24
hour recall) and appetite

Functional Ability (indicate ability to independently
perform following self care activities*):

_____ Dressing ______
Toileting ______ Bathing ______ Eating
______Ambulating

_____Shopping _____
Cooking _____ Housekeeping

*If unable to perform independently, describe:

Sleep/rest patterns: Ask about number of hours of sleep per
night, whether sleep is restful, naps, and use of sleep aids

Personal habits (tobacco, alcohol, caffeine, and drugs): Ask
about type, amount, and years used

Environmental history: Identify environment as urban/rural,
ask about safety of home, neighborhood, and work, type of home, heating and
plumbing, and smoke detectors

Socioeconomic status: Ask about health insurance

Family/social relationships: Ask about significant others,
individuals in home, and role within family Identify supports, family friends,
coworkers, and community agencies

Cultural/religious influences: Identify cultural and
religious influences on health

Mental Health: Ask about anxiety, depression, irritability,
stressful events, and personal coping strategies

Now answer the questions below: (5 points)

1 Was the
person willing to share the information? If they were not, what did you do to
encourage them?

2 Was there
any part of the interview that was more challenging? If so, what part and how
did you deal with it?

3 What
interviewing techniques did you use, eg silence, restating, etc?

4 Now that
you have taken a health history, discuss how this information can assist the
nurse in determining the health status of a client

5 Identify
one physical, one cognitive or psychosocial strength and one weakness you
believe this person possesses and state why you believe this to be true

What is a strength? This might be that a person’s
nutritional status appears to be excellent It may be that there is no
impairment of mobility They may have lots of friends with them so be socially
active

What is a weakness? This might be that a person does have
impaired mobility or perhaps imbalanced nutrition – more than or less than body
requirements It might be that they have a communication issue that you note or
perhaps seem to have a depressed mood, seem alone/isolated