NR 302 RUA Health Assessment

Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name

Date

Health History Assessment

The individual selected for this health assessment is SA, a 63-year-old Caucasian female residing alone in a rural area with strong family support. SA perceives health as a balanced state, involving regular exercise and a nutritious diet. She describes herself as between healthy and unhealthy due to some ongoing health issues. SA engages in physical activities about once a week and maintains a predominantly healthy diet, yet she is motivated to improve her overall well-being by enhancing her exercise routine.

SA’s medical history encompasses several chronic conditions, including degenerative disc disease, hypertension, hyperkinemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis. Her surgical history includes neck and back surgeries, gallbladder and cataract removal, and a hysterectomy. Her current medication regimen consists of Spiriva inhaler, Allegra, Valium, Zoloft, gabapentin, Lopressor, and Protonix. SA’s family history reveals that both parents had hypertension, potentially contributing to her own condition. Her mother had asthma, which could have influenced SA’s respiratory health, while her father, a cigarette smoker, was diagnosed with lung cancer, and her mother also suffered from anemia, requiring multiple blood transfusions.

Review of Systems

SA has minimal skin issues, limited to eczema, with normal nails and some greying hair. She reports no headaches, head injuries, or dizziness but does experience neck pain when turning her head to the right. No lymphatic issues are present. SA’s vision is slightly compromised due to cataracts, for which she wears glasses, and she underwent cataract surgery in June 2015. Her auditory health is good, with no ear infections or hearing issues. Although she has allergies to pollen and dust, SA experiences no significant sinus problems. Her mouth and throat health is generally good, without sore throat, lesions, or toothaches. While asthma and emphysema cause occasional shortness of breath, they do not hinder her ability to perform daily activities like cooking, cleaning, and self-care. Her only cardiovascular concern is high blood pressure, which she manages through medication and reduced salt intake.

Developmental Considerations

Having dealt with asthma since childhood, SA’s health condition has shaped her lifestyle significantly. Her respiratory limitations restricted her participation in sports and prolonged physical activities, impacting her social interactions and contributing to challenges with weight management. Throughout her life, SA has associated her struggles with weight control with her asthma, as the condition limited her physical activity options.

Cultural and Psychosocial Considerations

SA’s upbringing was marked by an interest in religion, specifically church attendance and Bible study, though her family did not share the same religious devotion. Her father’s discouraging remarks regarding her spiritual interests created a challenging environment, which hindered her connection with her faith community. Psychosocially, the loss of her husband nearly a year ago has heavily impacted SA’s social life. She finds it emotionally difficult to attend social events, as they remind her of activities once shared with her spouse. Despite this, her children visit regularly, with one visiting daily, and they maintain a weekly family night, which brings SA comfort and a sense of companionship.

Collaborative Resources and Reflection

SA has access to strong family support, including daily visits and assistance with doctor appointments. Additionally, her religious friends offer community support through shared church attendance and weekly social gatherings, providing emotional comfort. Her neighbor also joins her for regular exercise walks, fostering a supportive social and physical environment.

Reflecting on this assessment experience, I found my health assessment skills helpful in discussing SA’s medical history. However, I encountered challenges when addressing the review of systems due to SA’s difficulty understanding specific questions. To navigate this, I explained each topic in simpler terms. In retrospect, it would have been beneficial to further explore any cultural factors influencing SA’s health experience, as this could deepen the understanding of her health behaviors and concerns.

References

American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.

NR 302 RUA Health Assessment

Jarvis, C., Tarlier, D., Pelt, L. V., Andrews, M. E., & Jarvis, C. (n.d.). Physical examination and health assessment (7th ed.).

NR 302 Health Assessment I Health History RUA paper

Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name

Date

Demographic Data

L.S. is a 23-year-old Caucasian woman born on February 4, 1993, in Baltimore, Maryland. English is her primary language, though she has a basic understanding of Spanish. She completed her high school education in 2011 and now resides in Salisbury, where she balances her studies with a job as a veterinary receptionist/technician. L.S. currently lives with her boyfriend and his parents while saving to move out independently. She reports experiencing frequent headaches.

Health Perception

L.S. recognizes her obesity but is actively working on her physical health. She reports being mindful of her dietary habits and has taken up running regularly as part of her training for an upcoming marathon. Despite viewing herself as overweight, L.S. generally considers her health to be good and is highly focused on maintaining her current regimen to prepare for the marathon, which is scheduled in a few months.

Past Medical History

L.S. occasionally consumes alcohol on weekends when not working but is a non-smoker. She has no history of hospitalizations for significant health issues. However, she was previously diagnosed with shin splints, a condition that emerged during her high school soccer activities. For her headaches, L.S. takes 200 mg of Ibuprofen as needed for relief.

NR 302 Health Assessment I Health History RUA paper

Review of Systems

The interview with L.S. was conducted at a local coffee shop, providing a relaxed and comfortable setting for the discussion. L.S. appeared at ease and willingly responded to questions, making the interaction smooth. Although I initially felt slightly nervous, my preparation and application of class knowledge facilitated the process effectively. A casual conversation over coffee allowed us to build rapport, which fostered a level of trust that enabled L.S. to be open with her responses. While I gathered the necessary information, I noticed that I relied on closed-ended questions more than intended. Moving forward, I aim to incorporate more open-ended questions to encourage deeper discussion.

Reflection

The interview with L.S. was insightful and engaging. Conducted at her preferred coffee shop, the setting was comfortable, and L.S. felt at ease, which contributed to the openness of our conversation. Although I initially felt some nervousness, organizing my questions and applying what I had learned in class helped the interview proceed smoothly. The coffee shop setting allowed us to establish trust and rapport, which facilitated open communication. Although the trust built easily, I recognize that future interviews may not progress as smoothly, and I will be prepared to adapt as needed. I realized that I relied heavily on closed-ended questions and aim to use more open-ended questions in the future to promote more elaborate responses. Following the interview, I recommended that L.S. seek additional information about diabetes and nutritional values, and she showed genuine interest in understanding these topics better to support her long-term health.

NR 302 Week 4 Edapt

Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name

Date

Week 4 Edapt – NR 302 Vital Signs

Pulse Rate

Pulse rate generally varies by age, gender, and physical condition. In infancy and childhood, pulse rates are faster, slowing as individuals age. After puberty, females tend to have slightly faster pulse rates than males. For any client with an irregularly high or low pulse, it is essential first to verify these findings by assessing the apical pulse for one full minute. Only after a focused assessment is completed and findings are verified should healthcare providers be notified. Patient histories, including prior heart rate and rhythm, are accessible in the Electronic Health Record (EHR), eliminating the need for additional information from the client’s family.

Blood Pressure Physiology

The physiology of blood pressure (BP) involves both systolic and diastolic pressures, reflecting heart activity. Diastolic pressure, also known as the “bottom number,” measures arterial pressure during ventricular rest. The difference between systolic and diastolic pressures, known as “pulse pressure,” provides additional insights into cardiovascular health. Systolic pressure represents the heart’s force during contraction, while the diastolic reading occurs when Korotkoff sounds cease, marking relaxation. The term “auscultatory gap” refers to the absence of sound during BP measurement, indicating reduced peripheral blood flow.

Vital Signs and Abnormal Findings

Vital signs are fundamental indicators of health, with values varying across normal and abnormal ranges. For example, a temperature below 95.1 °F (35.1 °C) signals hypothermia, while a heart rate exceeding 100 bpm in adults is tachycardia. Respiratory rates of 12-20 breaths per minute are standard for adults, and deviations may indicate underlying health issues. Additionally, a BP reading above 140/90 mm Hg is classified as hypertension. Vital signs should be measured during specific circumstances, such as admission, after surgery, or before administering medications that affect heart rate, blood pressure, or respiratory function.

Vital Signs Table

References

American Nurses Association. (2020). Nursing: Scope and standards of practice. Silver Spring, MD: American Nurses Association.

NR 302 Week 4 Edapt

Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.). Wolters Kluwer Health.

NR 302 Exam 1

Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name

Date

Concept Review

1. Understanding Physical vs. Emotional Responses

Nursing questions can be objective, requiring simple, direct answers, or they may be more communication-focused, needing interpretative responses. Objective responses are typically prompted by questions such as “How do you?” or “What type of data?” and may specify physical aspects. Communication-focused questions often ask, “What factors?” or “How can improvement be achieved?” indicating an emotional or subjective response is required.

2. Communication Techniques in Nursing

Nurses need to choose between open-ended and closed-ended questions based on the context. Open-ended questions, such as, “Can you describe how you’re feeling today?” allow patients to share in-depth responses, especially helpful when gathering narrative information. Conversely, closed-ended questions like, “Did you take your medication today?” are useful for obtaining specific details or guiding conversations effectively. Cultural awareness also plays a crucial role; respecting and integrating patients’ cultural beliefs into care plans enhances rapport and supports holistic care.

3. Assessing Databases and Using SBAR

Different databases suit various scenarios: a complete database is appropriate for new patients, while a focused database may address a single, acute issue in returning patients. Emergency databases provide critical, immediate data, and follow-up databases focus on longer-term care. The SBAR (Situation, Background, Assessment, Recommendation) model assists in structured communication, summarizing patient situations, background, current assessments, and care recommendations effectively.

Nursing Assessment & Basics

1. Types of Databases and Their Applications

Different databases are utilized based on patient needs. A complete database captures a new patient’s full health history, while a focused database addresses specific concerns. For emergency cases, immediate critical information is gathered quickly, and follow-up databases support ongoing care. Recording patient histories accurately, including family medical histories using tools like genograms, provides a comprehensive overview of potential health influences.

2. Understanding Subjective vs. Objective Data

Subjective data reflects what the patient expresses (e.g., “I feel dizzy”), while objective data includes observed signs (e.g., an unsteady gait). Differentiating between these types allows for a well-rounded assessment, capturing both patient reports and measurable observations, such as elevated white blood cell counts for infection or visible signs like vomiting.

3. Pain and Priority Assessments

Pain is assessed based on the patient’s self-reported experience, making them the most reliable source for evaluating pain levels. Before administering pain medication, vital signs are reviewed to determine appropriate treatment. Priority assessments are divided into three levels: first-level (life-threatening, such as airway issues), second-level (urgent, non-life-threatening), and third-level (non-urgent needs like patient education).

Nursing Process and Developmental Care

1. The Nursing Process (ADOPIE)

The nursing process encompasses six essential steps: Assessment, Diagnosis, Outcome identification, Planning, Implementation, and Evaluation. This approach ensures a structured method to gather, interpret, and act upon patient information effectively. For example, in planning, a patient with a knee injury might have an end goal of ambulation, with physical therapy implemented as part of the care.

2. Developmental Considerations Across Ages

Patient comfort varies with age, from infants who benefit from calm voices to adolescents who require trust and confidentiality to discuss concerns openly. Aging patients may need slower assessment processes but should not be assumed to have cognitive impairments solely due to age.

3. Consciousness and Mental Status Assessment

Mental status assessment evaluates orientation (person, place, time, and situation) and consciousness levels, ranging from alertness to comatose states. The mini-mental exam is a quick tool for cognitive assessment. It is essential to keep safety protocols in mind, especially with patients showing signs of aggression.

NR 302 Exam 1

References

American Psychological Association. (2020). Publication Manual of the American Psychological Association (7th ed.). Washington, DC: American Psychological Association.