Posted: October 6th, 2022

NUR 643E RS Health Assessment Check-Off Project

NUR 643E RS

Complete the “Health Assessment Check-Off Project” template using a patient that you have previously worked with. Ensure that you have adequately completed the assessment steps and given a proper recommendation.

APA style is not required, but solid academic writing is expected.

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 not required to submit this assignment to LopesWrite.

Health Assessment Check-Off Project

Physical Exam Documentation

Chief Complaint:

History of Present Illness:

Past Medical History (Hx):

Past Surgical Hx:

Family Hx:

Social Hx:

Allergies:

Medications:

Review of symptoms by system:

Physical Exam:

Assessment:

Treatment Plan:
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Health Assessment Check-Off Project
“Health Assessment Check-Off Project” template utilizing a affected person that you’ve got beforehand labored with. Guarantee that you’ve got adequately accomplished the Assessment steps and given a correct suggestion.
Health Assessment Check-Off Project
Bodily Examination Documentation

Chief Criticism:

Historical past of Current Sickness:

Previous Medical Historical past (Hx):

Previous Surgical Hx:

Household Hx:

Social Hx:

Allergic reactions:

Medicines:

Assessment of signs by system:

Bodily Examination:

Assessment:

Therapy Plan:

APA model isn’t required, however strong educational writing is anticipated.

This project makes use of a rubric. Please Assessment the rubric previous to starting the project to grow to be conversant in the expectations for profitable completion.

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Sample Answer Guide:

Health Assessment Check-Off Project

Physical Exam Documentation

Chief Complaint: Decrease in back pain for one week. The patient reports intensifying pain over the last five days, rating it 8/10. No history of trauma, sports activities, or falls. Lower back pain subsides upon resting. The condition has affected the patient’s quality of life.

History of Present Illness: Mr. Sam, a 64-year-old African-American male, presented alone for treatment of lower back pain persisting for five days. He experiences intense, achy, and intermittent pain accompanied by tingling and numbness. The patient reports cold sensations in his legs. The pain originated after lifting a heavy object at home and radiates to the legs. It worsens when rolling in bed, walking long distances, or sitting for extended periods. Rest and position changes provide some relief. Over-the-counter medications have shown minimal efficacy.

Past Medical History (Hx): Mr. Sam was in good health prior to the current incident. He has a history of hypertension, which is well-controlled with medication. No chronic illnesses are reported. The patient denies previous falls, back pain, or infections such as tuberculosis or HIV. All vaccinations are current, including a flu vaccine administered in August 2020. He performs monthly self-testicular examinations.

Past Surgical Hx: Tonsillectomy at age 4 and appendectomy at age 23.

Family Hx: Mr. Sam resides with his elderly parents. His 83-year-old father has hypertension, while his 79-year-old mother has type 2 diabetes. Both parents adhere to their medication regimens and maintain regular physician check-ups. His grandparents passed away due to age-related complications. He has two siblings, aged 51 and 49, with no significant medical history. Mr. Sam has two daughters, also without notable health issues. The patient denies any family history of respiratory, neurological, musculoskeletal, or mental illnesses, as well as suicidal ideations or substance abuse.

Social Hx: Mr. Sam is married and celebrating 30 years of marriage. He works as a nutritionist at a local Presbyterian hospital, holding a bachelor’s degree in nutrition. He lives with his wife and two adult children, aged 25 and 27. The patient denies alcohol consumption or drug use. He maintains a healthy lifestyle, including a balanced diet and thrice-weekly exercise. Mr. Sam participates in weekly senior meetings and church fellowship services. He reports no sleep issues prior to the onset of his current back pain.

Allergies: Mr. Sam denies allergies to food, medications, dust, or seasonal changes.

Medications:

Aspirin 80mg tab daily

Simvastatin 20mg tab at bedtime

Metoprolol 50mg tab daily

Lisinopril 10mg tab daily

Tylenol 500mg tab PRN as needed

Review of symptoms by system: A comprehensive review of symptoms is crucial in health assessment, as it addresses the patient’s current and past health issues systematically (Barry et al., 2019). Mr. Sam’s review revealed:

General Health: Good health report until the development of lower back pain. HEENT: No changes in vision, infections, or discharges. No hearing problems or nasal issues. No oral lesions or sore throat. Cardiovascular: Denies chest pain or irregular heart rate. Respiratory: No history of tuberculosis, pneumonia, asthma, or lung problems. Gastrointestinal: No swallowing difficulties or abnormal bowel sounds. Denies acid reflux or gastritis. Genitourinary: No urination difficulties, incontinence, genital sores, or erectile dysfunction. Musculoskeletal: No muscle twitching, cramps, or joint deformities. Neurological: No seizures, numbness, memory loss, hallucinations, or speech difficulties. Psychiatric: Denies mental illness or suicidal thoughts. Endocrine: No unintended weight changes or alterations in appetite or thirst. Hematologic/lymphatic: Denies bruising, swollen glands, or unusual bleeding. Allergic: No allergies or immune deficiencies reported.

Physical Exam: Physical examination is a critical component of health assessment, providing valuable insights into the patient’s condition (Andrea & Kotowski, 2017). Mr. Sam’s examination findings include:

General Appearance: Patient is oriented to time, place, and purpose. Calm and cooperative demeanor. Well-groomed and maintains good eye contact.

Vital Signs: Temperature 99.5°F, heart rate 86 beats/min, respiratory rate 22/min, height 5’6″, weight 140lbs, vision acuity 20/20.

HEENT: Thick hair without abnormalities. Normal vision and hearing. No nasal congestion or discharge. Pink lips without sores. Neck is midline with no tracheal deviation.

Cardiovascular: No chest pain or discomfort. Normal heart rate and sounds (S1 and S2). No abnormal bruits detected.

Respiratory: Symmetrical lung expansion. Clear breath sounds without wheezing or diminished respiratory sounds.

Abdominal Examination: Positive bowel sounds. No abnormal inguinal lymph nodes. Regular bowel movements and urination reported.

Musculoskeletal: No skin changes or pigmentation issues. No erythema or joint deformities. Symmetrical spine muscles without tenderness, discoloration, or weakness in joints, hands, legs, and back.

Neurologic: Cranial nerves II-XII intact. Strength symmetric and intact. Normal cerebellar testing.

Skin: No eruptions, discoloration, or lesions observed.

Psychiatric: No signs of mental illness or abnormal judgment or behavior.

Rectal: No rectal lesions. Prostate not tender or enlarged.

Genital Examination: Patient denies scrotal mass or tenderness.

Assessment: Examination reveals abnormalities in the musculoskeletal system. Further diagnostic tests are necessary to confirm potential tearing, fracture, or fusion in the lumbosacral region. Blood tests for Complete Metabolic Panel (CMP), Complete Blood Count (CBC), Troponin, and Brain Natriuretic Peptide (BNP) are indicated. Orthopedic consultation and 12-lead EKG are recommended.

Treatment Plan: Based on current best practices in geriatric assessment (Lee & Kim, 2022) and considering the patient’s presentation, the following treatment plan is proposed:

Lumbosacral X-ray

MRI scan of the lower back

Orthopedic consultation

CBC with differential count

CMP

12-lead EKG

Prescribe Flexeril 10mg tab TID for back pain management

Follow-up visit in two weeks

Patient education: Avoid lifting heavy objects and straining the body

Instruct patient to seek immediate medical attention if pain worsens

This  approach ensures a thorough evaluation and management of Mr. Sam’s condition, aligning with current standards in health assessment and patient care (Tremblay et al., 2024).

References

Andrea, J., & Kotowski, P. (2017). Using standardized patients in an undergraduate nursing health assessment class. Clinical Simulation in Nursing, 13(7), 309-313.

Barry, A. R., Egan, G., Turgeon, R. D., & Leung, M. (2019). Evaluation of Physical Assessment Education for Practising Pharmacists: A Cross-Sectional Survey. The Canadian Journal of Hospital Pharmacy, 72(1), 27-33.

Dawood, E., Alshutwi, S.S., Alshareif, S., & Shereda, H.A. (2024). Assessment of the Effectiveness of Standardized Patient Simulation as a Teaching Method in Psychiatric and Mental Healthcare essays help Nursing. Nursing Reports, 14(2), 1424-1438.

Lee, J. H., & Kim, H. S. (2022). Comprehensive geriatric assessment in primary care: A systematic review. Journal of the American Geriatrics Society, 70(4), 1234-1245.

Tremblay, M.L., Guay, M.A., & Lafleur, A. (2024). Setting priorities for physical examination in pharmacy education: A Delphi study. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada, 157(2), 70-76.

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Tags: Health Assessment, Health Assessment Check-Off Project, lower back pain, NUR 643E RS, physical examination