...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: xx |Date: 03/22/2015 | |Client/Patient Initials: I.F |Sex: Female |Age: 76 | |Occupation of Client/Patient: Stay at home | | |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): | | |dizziness once in a while. ...
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...limits a person’s movement, senses, abilities or activities. ‘The Disability Act 2006 applies to disability service providers funded under the Disability Services program of the Victorian Department of Human Services (DHS). It replaces the intellectually Disabled Persons’ Services Act 1986 and Disability Services Act 1991’. This Act involves principles for people with a disability and for the disability services, in which provide a framework for the quality of services in line with the vision for people who suffer from a disability. These principals include; ‘respect for their human worth and dignity as individuals, live free from abuse, neglect or exploitation, realise their individual capacity for physical, social, emotional and intellectual...
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...Family Health Assessment Stephanie Beck Grand Canyon University Family Centered Health Promotion Home Nurs 429V August 9, 2015 Family Health Assessment The Family Health Assessment is used as an all-inclusive tactic to guarantee the health and fitness of individuals and their families; it focuses on ensuring that families recognize their health needs. (Edelman, 2010, Chapter 6 &7) I have had the privilege of interviewing the Varcela family, who is a Hispanic family which consist of Mom, Dad, and 2 kids, who are twins a boy and a girl. Dad (42) who works in construction work, Mom (38) is a surgical scrub tech; the children are 9 years old, in the 3rd grade. The data that is collected came from open-ended questions that were asked by myself. This information was then used to formulate a nursing diagnosis, also to show the audience how the families live their lives, and how they deal with the struggles of life, health concerns, beliefs, values, activity’s, and relaxation. Values and Health Perception While assessing the Varcela family, they have very strong spiritual beliefs in the Catholic religion. They valve each other as family and not just the immediate family but the extended family as well, because mom has a host of sisters and brothers, cousin, nieces, and nephews, so family Is very important for her. They are all in pretty good health, the children both are healthy kids, they were full term babies, mom states, “ she could lose a couple pounds, “ but otherwise...
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...Nursing 122 Fundamentals of Neuro-Sensory nursing --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- Review major structures and functions of both central and peripheral nervous system. (Carolyn Jarvis, Physical Examination and Health Assessment, 3rd ed., pages 688-692 Structure and function of the CNS and PNS --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- Potter and Perry, Fundamentals of nursing (8th), Chapter 16 p. 210-211 Types of Data --There are two primary sources of data: subjective and objective. Subjective data are your patients’ verbal descriptions of their health problems. Only patients provide subjective data. For example, Mr. Jacobs's report of incision pain and his expression of concern about whether the pain means that he will not be able to go home as soon as he hoped are subjective findings. Subjective data usually include feelings, perceptions, and self-report of symptoms. Only patients provide subjective data relevant to their health condition. The data sometimes reflect physiological changes, which you further explore through objective data collection. --Objective data are observations or measurements...
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...Occupation: Aircraft mechanic | Source of Data: Patient | HISTORY Reason for Seeking Care/Presenting Problem Cirrhosis Congestive Heart Failure Coronary Heart Disease Diverticular Disease Depression Diabetes, Type 1 x Diabetes, Type 2 Emphysema Glaucoma Gout Hemophilia Hernia Hypertension Irritable Bowel Syndrome Multiple Sclerosis Osteoporosis Parkinson’s Disease Psoriasis Renal Failure Seizure Disorder Thyroid Disease Venous Insufficiency Vision Disturbance Female: Dysfunctional Uterine Bleeding Other (describe):asthma Fibrocystic Breast Disease Premenstrual Syndrome Male: Prostate Disease Current medications (include prescription, over-the-counter, herbs, and vitamins): Name of Drug | Dosage/Frequency | Last Dose Taken | Reason for Taking | Ventolin INH | 2 puffs PRN | 3 years ago | Asthma | Metformin | 500 mg PO BID | 11/8/13 started on 10/28/13 | Diabetes T 2 | Multivitamin | 1 tab PO daily | 11/8/13 | Supplement | | | | | Allergies to Medication/Foods/Medical Products/Other (e.g., latex, contrast, tape): Allergic To | Type of Reaction | PCN | Hives, difficulty breathing | | | | | | | Current medical treatments (e.g., breathing treatments, dialysis, wound dressing): Past Health History Childhood illnesses (check all that apply): Measles Mumps | Rubella | X Chicken pox | Pertussis x Influenza | Ear infections | Throat infections...
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...| Date: April 20, 2013 | Biographical Data | Patient/Client Initials: MT | Phone No: | Address: | Birth Date: 10/19/1994 | Age:18 | Sex Female | Birthplace: Richmond, VA | Marital Status: Single | Race/Ethnic Origin: African American | Occupation: Cashier | Employer:VCU Health System | Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)Patient works part-time as a cashier and requires assistant to supplement her income. She receives monthly food stamps and funds from her maternal grandmother to help with living expenses. Medical, dental and vision insurance coverage is available through the patient’s mother. She has no disability limiting her from working or engaging in other activities | Source and Reliability of Informant:Information obtained from patient who is a good historian and is well informed about her health history | Past Use of Health Care System and Health Seeking Behaviors:She uses the health care system for episodic illnesses and recently sought medical care for UTI. Patient understand the importance of obtaining health care when necessary as demonstrated her recent visit to the doctor to for UTI | Present Health or History of Present Illness:Patiently she has chronic UTI related to congenital overactive bladder and pre-hypertension | General Health: (Patient’s own words)“Although I have high blood pressure...
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...The human brain is the most complex, most sophisticated body organ which makes us superior among other living creatures. It is the vessel of the greatest power ever invented. Since it is a treasure not any pleasure could ever equal it is encapsulated on a hard mass of bone to keep its treasure. The human brain can be divided into four major divisions: The cerebrum, the diencephalon, the cerebellum and the midbrain. The first division is further subdivided into four parts. The frontal lobe, the parietal lobe and the occipital lobe. In the frontal lobe, the precentral gyrus (motor cortex) controls voluntary motor activity. The Broca’s area coordinates the complex muscular activity of the mouth, tongue, and larynx and makes expressive motor speech possible. The frontal area also controls attention and concentration, motivation, ability to formulate goals, the ability to plan, the ability to initiate and maintain action, ability to self monitor and the ability to use feedback (executive functions). These areas contribute to reasoning, problem solving and emotional stability. The parietal lobes interpret temperature, touch and pleasure. Concept formation and abstraction happens and are formulated in this area. The parietal lobes form two sides; the left parietal lobe and the right parietal lobe. The left parietal lobe assists with right and left orientation and mathematics, while the right parietal lobe is used for awareness, as to shape (steriognosis) and size...
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...and health concerns. M. Source and Reliability of information * Client herself, who seems reliable. II. Reason for Seeking Care * The client came to the hospital because o to consistent back pain which is interfering with ADLs. The pain has been present for the past two weeks. Back pain is located in the lower lumbar area. It is a throbbing like pain that occurs through out the day. The severity of pain on a scale of 1-10, client rated 8. The pain causes her to sit down or lay down until pain improves. Pain lasts for about 15 minutes. Not standing up usually relieves the pain. 1. When did symptoms appear? - Pain began two weeks ago when she was cleaning. 2. How often? - Pain has reoccurred everyday. 3. Type of activity when patient’s symptoms occurred. - The problem happened when the patient was cleaning. III. Past Health History * Client has borderline blood pressure and cholesterol, controlled by medication 1. General Health - Feels tired and likes to lie down in between. The patient wakes up at least two times at night to go to bathroom. She does not eat junk food. Overall her health is good. She likes to move around and not depended on others for her ADLs. Client has no allergies to food or medications. 2. Accidents...
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...have any difficulty swallowing? Sleep/Rest: 1. How many hours do you sleep? 2. Do you take any medication to sleep? 3. Do you have any sleep apnea? Elimination: 1. How often do you have bowel movement? 2. Do you have any constipation or diarrhea? 3. Do you have any bladder incontinence? Activity/Exercise: 1. What are your daily activities? 2. Do you exercise regularly? 3. Are you physically strong or weak? Cognitive: 1. Do you have any problem with memory or concentration? 2. Do you have difficulty making decisions? Sensory-Perception: 1. Do you have any vision problem? 2. Do you have any hearing problem? Self-Perception: 1. Do you feel anxious or depressed? 2. Do you feel loss of hope? 3. Are you taking any antidepressant? Role Relationship: 1. Are you married or single? 2. How many kids do you have? 3. Are you employed? Sexuality: 1. Are you sexually active? 2. Do you have any sexual transmitted disease? Coping: 1. How do you handle stress? 2. Are you relaxed most of the time? 3. Are you taking any medication, drugs, or alcohol to relax? Summarization of Functional Health Patterns: A family consists of father, mother, and children. There are 11Functional Health Patterns. Values, health perception, Nutrition, Sleep/Rest, Elimination, Activity/Exercise, Cognitive,...
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...When blood fills in intracranial space, intracranial pressure build up, brain tissue absorbs blood, and neural activity is diminished and then cell death begins. Depending on the type of vessel rupture, hemiplegia and hemiparesis usually occurs. With hemiplegia and hemiparesis, one side is affected and musculoskeletal disabilities develop. Sensorial, cognitive and behavioral changes can occur and the patient usually has ineffective coping due to loss, resulting in depression. Specific care must take place for the safety of the patient to prevent skin breakdown and falls. But through physical therapy and occupational therapy, a full recovery can happen. But for those with lasting disabilities, life can be challenging. Physical and occupational therapy can at least improve quality of life. It is up to the nursing staff, unlicensed personal, and family members...
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...1.0 INTRODUCTION Children exhibit differences from one another in terms of their physical attributes (e.g., some are shorter, some are stronger) and learning abilities (e.g., some learn quickly and are able to remember and use what they have learned in new situations; others need repeated practice and have difficulty maintaining and generalizing new knowledge and skills). The differences among most children are relatively small, enabling these children to benefit from the general education program. The physical attributes and/or learning abilities of some children, however—those called exceptional children—differ from the norm (either below or above) to such an extent that they require an individualized program of special education and related services to fully benefit from education. The term exceptional children according to Heward, W. L. (2006 ) includes children who experience difficulties in learning as well as those whose performance is so superior that modifications in curriculum and instruction are necessary to help them fulfill their potential. Thus, exceptional children is an inclusive term that refers to children with learning and/or behavior problems, children with physical disabilities or sensory impairments, and children who are intellectually gifted or have a special talent. Although the terms impairment, disability, and handicap are sometimes used interchangeably, they are not synonymous. Impairment refers to the loss or reduced function of a particular body...
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...neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics. The disorder is named for Dr. Georges Gilles de la Tourette, the pioneering French neurologist who in 1885 first described the condition in an 86-year-old French noblewoman. The early symptoms of TS are typically noticed first in childhood, with the average onset between the ages of 3 and 9 years. TS occurs in people from all ethnic groups; males are affected about three to four times more often than females. It is estimated that 200,000 Americans have the most severe form of TS, and as many as one in 100 exhibit milder and less complex symptoms such as chronic motor or vocal tics. Although TS can be a chronic condition with symptoms lasting a lifetime, most people with the condition experience their worst tic symptoms in their early teens, with improvement occurring in the late teens and continuing into adulthood. What are the symptoms? 8 Tics are classified as either simple or complex. Simple motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups. Some of the more common simple tics include eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocalizations might include repetitive throat-clearing, sniffing, or grunting sounds. Complex tics are distinct, coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial...
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...Advance concept of nursing I Unit 1 Nursing process The nursing process is an organized sequence of problem solving steps used to identify and to manage the health problems of clients .The nursing process is the framework for nursing care in all health care settings.When nursing practice follows the nursing process, clients receive quality care in minimal time with maximal efficiency. The steps of nursing process 1)Assesment 2)Diagnosis 3)Planning 4)Implementation 5)Evaluation Assessment An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation. Diagnosis The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard...
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...History and Physical Assessment: a. Biographical Data: A.G. is a 56 year old Hispanic male who is married with three children. All three children are young adults and living at home. He completed the sophomore year of high school, and works in the fields. Patient can communicate efficiently in English, but more articulate in Spanish. He is insured by Blue Cross. The patient’s primary diagnosis is ascending colon polyp. The operative procedure is DaVinci assisted Laparoscopic right colon resection possible ostomy. Patient was able to answer most of the questions. His wife translated whatever needed more explanation. Client’s Current Health Status b. Chief Complaint: Patient stated his chief complaint was that the doctor advised surgical removal of a polyp. “I went to the doctor because of my age {56} for a colonoscopy and the doctor said I had 3 polyps. The doctor got the other two polyps but said he must cut out the polyp or it will rupture in the colon” c. Presenting Symptoms: No apparent evidence of pain. The onset of his diagnosis began when A.G. was having a diagnostic test done. A.G. went to the doctor on January 23 for a routine colonoscopy and found out during the test that the third polyp was too big, but benign. A.G. states “The location of the polyp was in the right side. It is localized in a small area, a couple of inches of the bowel” A.G. states he feels no pain. Due to the location of the bowel, there are no signs or symptoms that A...
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...neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics. The disorder is named for Dr. Georges Gilles de la Tourette, the pioneering French neurologist who in 1885 first described the condition in an 86-year-old French noblewoman. The early symptoms of TS are typically noticed first in childhood, with the average onset between the ages of 3 and 9 years. TS occurs in people from all ethnic groups; males are affected about three to four times more often than females. It is estimated that 200,000 Americans have the most severe form of TS, and as many as one in 100 exhibit milder and less complex symptoms such as chronic motor or vocal tics. Although TS can be a chronic condition with symptoms lasting a lifetime, most people with the condition experience their worst tic symptoms in their early teens, with improvement occurring in the late teens and continuing into adulthood. What are the symptoms? Tics are classified as either simple or complex. Simple motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups. Some of the more common simple tics include eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocalizations might include repetitive throat-clearing, sniffing, or grunting sounds. Complex tics are distinct, coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial...
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