NSG 330 Stratford University CH28 Biographical Data & Health Assessment Paper This should include the cultural assessment, genogram, and health history. Ap

NSG 330 Stratford University CH28 Biographical Data & Health Assessment Paper This should include the cultural assessment, genogram, and health history. Appropriate headings required in each area. References required for unoriginal work or if using a genogram generator.Student may use pages 29 to 36 in Jarvis Student Laboratory Manual as reference guideStudent may also use end of Chapter 28 in Jarvis textbook as guide and samples of health histories (Pg 778-782)Please see attachment for Instructions/Rubric, sample and Book pages. NSG330 Health Assessment and Diagnostic Reasoning
Grading Criteria for Partner Complete Health History Paper
Student Name:__________________________________________ Date:____________________
Format
Possible Points
Paper is typed and turned in on time,
5
with coversheet
Words in history are selected by
student and not copied directly from a
textbook.
Student’s Score
5
Content
Biographical Data, Source and
Reliability of Information, Reason for
Seeking Care are complete.
Possible Points
5
History of Present Illness is written in
paragraph form.
Present health included.
10
Past Medical History, Past Surgeries
and Hospitalizations, Medications and
Allergies listed, with dates.
10
Social History (Alcohol, tobacco,
drugs, marital , including health
status.
10
Construction of Genogram
10
Review of Systems – discuss each
system and use abbreviated format,
not complete sentences
Functional Assessment (Including
Activities of Daily Living)
Total
30
Student’s Score
15
100 points
Actual points =
Student may use pages 29 to 36 in Jarvis Student Laboratory Manual as reference guide
Student may also use end of Chapter 28 in Jarvis textbook as guide and samples of health histories (Pg 778782)
NSG330
History & Physical Format
Write this up with these headings.
SUBJECTIVE (History)
Identification name, address, tel.#, DOB, informant, referring provider
CC (chief complaint) list of symptoms & duration. reason for seeking care
HPI (history of present illness) –
PQRST Provocative/palliative – recipitating/relieving
Quality/quantity – character
Region – location/radiation
Severity – constant/intermittent
Timing – onset/frequency/duration
PMH (past medical /surgical history) general health, weight loss, hepatitis, rheumatic
fever, mono, flu, arthritis, Ca, gout, asthma/COPD, pneumonia, thyroid dx, blood
dyscrasias, ASCVD, HTN, UTIs, DM, seizures, operations, injuries, PUD/GERD,
hospitalizations, psych hx
Allergies Meds (Rx & OTC)
SH (social history) birthplace, residence, education, occupation, marital status, ETOH,
smoking, drugs, etc., sexual activity – MEN, WOMEN or BOTH
CAGE Review
Ever Feel Need to CUT DOWN
Ever Felt ANNOYED by criticism of drinking
Ever Had GUILTY Feelings
Ever Taken Morning EYE OPENER
FH (family history) age & cause of death of relatives’ family diseases (CAD, CA, DM,
psych)
SUBJECTIVE (Review of Systems)
skin, hair, nails – lesions, rashes, pruritis, changes in moles; change in distribution;
lymph nodes – enlargement, pain
bones , joints muscles – fractures, pain, stiffness, weakness, atrophy blood – anemia,
bruising
head – H/A, trauma, vertigo, syncope, seizures, memory eyes- visual loss, diplopia,
trauma, inflammation glasses ears – deafness, tinnitis, discharge, pain nose discharge, obstruction, epistaxis
mouth – sores, gingival bleeding, teeth, abn. taste, jaw pain
throat – ST, hoarseness, voice changes, URI
neck – swelling/stiffness, adenopathy, goiter,
breasts – lumps, pain, nipple discharge, last mammogram
endocrine – polyphagia/dipsia/uria, dec. energy/fatigue
respiratory – dyspnea, orthopnea, wheezing, cough, sputum, hemoptysis, pain, pleurisy,
night sweats, TB, #pillows, pneumonia, asthma
CV (cardiovascular) – CP, palpitations, claudication peripheral edema, ascites, cold feet,
phlebitis, cyanosis
GI – appetite/wgt change, dysphagia, N/V, hematemesis, BRBPR, melena, abd,
pain/colic, icterus, diarrhea, constipation, change in bowels, tenesmus,
hemorrhoids ,rectal pain, hernia
GU – polyuria, oliguria, dysuria/strangury, hematuria, pyuria, incontinence, nocturia, pain
passage of stones, UTI, pyelo & STD hx
MS – arthralgia, arthritis, myalgia, joint stiffness/swelling/ heat/pain, podagra/gout
nervous – smell, chewing, visual, facial weakness, hearing, balance, speech &
swallowing, taste,
motor – weakness, paralysis, atrophy, seizures, incoordination
sensory – pain, paresthesias, anesthesia
autonomic – incontinence, sweating, erythema, cyanosis, pallor, temp sensitivity
mental status – relations w family, lability of mood, hallucinations, delusions,
depression, somnolence, insomnia
OBJECTIVE (Physical Exam – sample recordings)
vital signs & general appearance: age, sex, well developed/nourished, appears stated
age, NAD
head – normocephalic, no masses /lesions, cicatrices, malar flushing eyes – visual fields
intact (cut)by confrontation, PERRLA , conjunctiva clear, sclera white, anicteric,
(1-2 beat nystagmus on lateral gaze.) EOMI, no ptosis; fundi: red reflex present
(B). discs flat w sharp margins, vessels present w/o crossing defects, retinal
hemorrhages
ears – TM’s non-injected(erythematous, bulging), good light reflex, no protrusion or
retraction; Weber midline, Rinne ac>bc, Whisper test 3:3
nose – nares patent, no deformity, septal deviation or perforation
throat – pharynx non-injected, palate rises symmetrically, gag present,
mouth – buccal mucosa, moist and intact, tonsils present, dentition intact, caries, tongue
midline w/o fasciculations
neck, axilla & breasts – no LAD (lymphadenopathy), masses, or thyromegaly/focal
lump, carotid pulses 2+ & = (B), no bruits, supple full ROM trachea midline,
breasts symmetric, no retraction, lesions, masses or tenderness
back, thorax & lungs – chest expansion symmetric, CTA (clear to auscultation), eupnea,
no adventitious sounds (rales, crackles, wheezes)
CV (cardiovascular) – RRR no m/r/g (systolic ejection murmur, rubs, gallops)
abdomen – soft non-tender w/o masses, tympany to percussion in all 4 quads, BS
present
(hyper/hypoactive, absent); no HSM (hepatosplenomegaly), no bruits
extremities – extremity size symmetric w/o swelling/atrophy, temp warm (B). All pulses
present, 2+ &= (B), no LAD,
skin – pink-tan color, good turgor w/o lesions, redness, cyanosis, edema or cicatrices;
nails – no clubbing or deformities w good cap refill
musculoskeletal – gait normal, able to tandem walk, no Rhomberg’s sign; joints and
muscles symmetric, no swelling, masses, deformity or tenderness to palpation; no
heat or swelling of joints; full ROM; muscle strength 5/5- able to Amitin flexion
against resistance & w/o tenderness
muscle grading – evaluate D (deltoid), T (triceps), B (biceps), WF (wrist flexion), WE
(wrist extension), Quad (quadriceps), PF (plantar flexion) DF (dorsiflexion)
scoring 0-5 out of 5 according to following scale:
5
NormalComplete ROM against gravity with full resistance
4
Good Complete ROM against gravity with some resist
3
FairComplete ROM against gravity
2
Poor Complete ROM with gravity eliminated
1
TraceEvidence of slight contractility. No joint motion
0 Zero No evidence of contractility
genitalia/rectum – no lesions, inflammation or discharge from penis, rectum: no fissure,
hemorrhoids, fistula or lesions in perianal area; sphincter tone good; prostate not
enlarged, no masses, nodules or tenderness. Stool brown, guaiac neg.
pelvic – no vaginal/cervical lesions, uterus size & position; no adnexal tenderness
nervous – (LOC, DTR’s, MMS) – CN II-XII grossly intact, alert oriented, cooperative
sensory – pinprick, light touch & vibration intact; proprioception tested (unable to
differentiate sharp/dull mid-calf
motor – no atrophy, weakness, tremors or clonus; RAM (rapid, alt. movement) finger-tonose/heel-to-shin intact; Rhomberg negative
DTR’s – all 2+ & = (B); Babinski absent toes upgoing, downgoing or equivocal
(inconclusive); plantar response in extensor on (L); Naming & repetition intact;
memory 3:3; (B) Pronator drift – (R)>(L); gaze preference; neglect; extinguishing
sensory (light touch to ea. ext then to both simultaneously): extinguishes (L or R)
side to direct sen. stim.
reflex grading – evaluate biceps (C5, C6); triceps (C6, C7, C8); brachioradialis (C5,
C6); patellar (L2, L3, L4); Achilles’ (S1, S2); plantar/Babinski (L4, L5, S1, S2)
based on following scale:
4+ very brisk/hyperactive – clonus
3+ more brisk than average
2+ average/normal
1+ low normal/diminished
0
no response or equivocal
Cranial Nerve Evaluation (using specific tests)
CN I (Olfactory) – smell mint leaves/tobacco
CN II (Optic) – visual acuity & funduscopic
CN III (Oculomotor) – pupillary reaction
CN IV (Trochlear) – pupillary reaction
CN V (Trigeminal) – clench teeth, open jaw, lip/chin test for light touch CN VI
(Abducens) – EOM
CN VII (Facial) – raise eyebrow/frown/show teeth/smile/puff cheek
CN VIII (Acoustic) – whisper test; Weber/Rinne tests
CN IX (Glossopharyngeal) – hoarseness, tongue movement
CN X (Vagus) – saying “ah,” & note palate and uvula move upward
CN XI (Spinal Accessory) – shrug shoulders
CN XII (Hypoglossal) – inspect tongue for atrophy/fasciculations

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