Type: Written Health and Physical Assessment

Subject: Health and Physical Assessment

Subject area: Nursing

Education Level: Undergraduate/College

Length: 12 pages

Referencing style: APA

Preferred English: US English

Spacing Option: Double

Adult History and Physical Assessment

Brown 

California University of Pennsylvania

NUR 350-G02

March 11, 2019

Adult History and Physical Assessment

1. The Complete Data Base
   1. Subjective Data
      1. Psychological Data
         1. Client’s response to health and illness

1. When asked how Vonnie views health, her response was “It is very important but not the point where you obsess over it.”  Vonnie said, “For instance if there is food I want to eat, I will just eat it.”  Vonnie states that she hopes for the future of her health is to be off all of her medications, especially her “sugar” medications.  She states that she wants her blood glucose to be at levels that do not require her to take any medications for diabetes.

2. Cultural implications for health care

1. Vonnie practices the Catholic religion.  She was raised by her mother in the Catholic Church.  She attended Catholic grade school and high school.  Vonnie went to mass every Sunday when she was a child, however she only goes on special occasions and holidays now.  She loves to support the local fish fries during lent as her mother was very active in the church and insisted that Vonnie go to fish fries with her every Friday during lent.  Mary thinks that her mother’s involvement in fish fries when she was younger could have contributed to her obesity.  
2. Vonnie does not have any genetic disorders in her family that she is aware of.  Vonnie does know that diabetes and heart disease are prevalent in her family history.  Vonnie says she thinks that hypertension if probably in her genes and has been passed to her from previous generations.

c. Developmental level of the client  

1) Vonnie is in the seventh stage of Erickson’s Developmental stages, generativity versus stagnation.  Vonnie has been married for 22 years to her husband Kenrick.  They have three children together, two girls and one boy.  They have Three grandchildren, one of whom Vonnie helps take care of when her daughter is at work.  Vonnie’s daughter is a single mother, so Vonnie helps her take care of the young boy who is six years old.  She has been helping to take care of him ever since he was born.  Vonnie’s adult daughter lived with Mary and her husband when he was born so that they could help take care of the newborn.  Vonnie works full-time (she was working four 10-hour long shifts per week but is now working three 12 hour shifts).  Vonnie is in the generativity versus stagnation stage as she is “making her mark” on the world through helping to raise a child in this current day and age and also creating and accomplishing things that make the world a better place for her grandchild.  According to Pratt (2013), research of generativity versus stagnation usually involves young to middle adult participants however it may be beneficial to involve older adults as the enjoyment of being a grandparent and its role pertaining to generativity may show reports of enjoyment among older adult participants.

2)  Vonnie was raised by her mother in the city of Pittsburgh, Pennsylvania.  She lived in a part of the city called Crafton.  She is an only child; her mother was a secretary and worked full-time.  Her father died when she was very young.  She vaguely remembers her father, her memories of him were not good memories.  Her father died of a heart attack.  Vonnie has very fond memories of her mother, they had a very close relationship.  Vonnie misses her mother a lot.  She says that her mother taught her how to be a good person, how to love, and how to be a good mother.  Vonnie’s mother died shortly after Vonnie had her first child, in her late twenties.  She married in her late thirties and is still with her husband, they have three children together, two sons (38 years old and 34 years old) and a daughter (32 years old).  They have three grandchildren together and is helping to raise and take care of one grandchild.  Their grandchild has recently moved out of their house and into an apartment with his mother (their daughter) and their daughter’s new boyfriend.  Vonnie states that she misses her grandchild but is happy to have the house back to herself and her husband.  Vonnie is very proud of her daughter who raised a child on her own as a single mother.  She is happy that her daughter has found a boyfriend that makes her happy and is very good with her grandchild.  Per Vonnie, he is a police officer and a really nice man.  She hopes that her daughter will marry him.

Vonnie enjoys bowling in a league and relaxing at home on her days off.  She used to watch her grandchild on her days off but now that he is in daycare she gets to enjoy her time alone.  She hopes to retire one day and just relax.

2. Sociological Data

   1. Client’s relationships with significant others   

1. Vonnie lives in the North Hills of Pittsburgh, PA with her husband Leonard, her 38-year-old son Lennie, and her dog Molly.  She hopes that her son will move out soon.  She states that she loves him very much but he needs to get his own place.  He cannot seem to keep a job.  Her husband works as a truck driver at night and her dog keeps her company while her husband is away.  Her other two children live close by.  Her other son is newly married and is trying to start a family with his new wife.  Vonnie says that she is excited for them and cannot wait to have more grandchildren.  Her daughter lives close and they see each other almost every other day.  Vonnie helps pick her grandson up from the nus stop.  She and her daughter enjoy shopping and running errands together.  Vonnie enjoys going out with her friends from church and states that she has a lot of really good friends at work.  She says that the most special people in her life are her daughter and her grandchildren.  

2. Occupational history 

1. Vonnie works at a hospital as the Health Unit Coordinator.  She describes her job as being a secretary.  She does not report any exposure to toxic chemicals.  She does report that she is exposed to a lot of beeps and ringing noises when the monitors go off.  She works in the recovery room where there are quite a few portable x-rays taken post-op so she does have some exposure to radiation.  She tries to move away from the machine when they take the x-rays but sometimes she does not get out of the way in time.  She works on the computer all day and does not get much exercise at work.  She thinks this does contribute to her obesity.  

2. She does not operate any heavy machinery.  Sometimes when the nursing assistant is late or not there she helps gather patient belongings and distribute them around the unit which can become strenuous especially during winter months when patients bring a lot of extra stuff with them to the hospital and things get heavy.

3. Vonnie describes her job as stressful at times but she thoroughly enjoys the people she works with (most of them she says).  She says that she coordinates tasks with surgeons and nurses, checks orders, coordinates bed assignments with the bed flow nurse, and helps the charge nurse with post-op bay assignments.  She describes her job as very stressful.  She states that she sometimes gets very frustrated and wishes things would run smoother.  She says that there have been a lot of changes in the department lately and she wishes that the people in charge would get things together.  She also wishes to be paid more for her time and effort.

3. Educational and economic resources

1. Vonnie’s highest level of education is high school graduate.  Vonnie started working as a secretary shortly after high school and has been in the field ever since.  She never wanted to or felt the need to go to college plus she says that her mother did not have the money for it.

2. Vonnie has health insurance through work.  She went through a period several years ago where she lost her health insurance because the hospital where she worked had to let her go because she could not work all 40 hours due to chemo treatments, she needed for colon cancer.  She said that was one of the hardest times of her life.  Not only was she recently diagnosed with cancer but her job let her go because of it and now she did not have insurance.

B. Objective Data

1. Vonnie is a 57-year-old female.  Address, phone number, and insurance information has been omitted from this assessment. 

a. Vital signs: height-165 cm, weight-95 kg.  Blood pressure 154/85, pulse 61, respiratory rate 16, oxygen saturation 98% on room air, temporal temperature 97.6 F. She does not use dentures or hearing aids.  She has no known drug allergies.  Mary uses reading glasses to see things up close.  She does not use contact lenses, dentures, hearing aids or any assistive devices for mobility.   She states that she eats three meals a day.  This morning for breakfast she ate two scrambled eggs with white toast and drank one cup of coffee with sweet and low and creamer.  For lunch she had a tuna salad sandwich and some chips, and for dinner she plans on stopping on her way home to pick up hoagies for her and her husband to eat for dinner.  She plans on getting an Italian sandwich with French fries.  She always carries snacks with her because she is a type 2 diabetic and can feel it when her sugar runs low.  She usually has some trail mix for a snack and/or some fruit.  She also eats candy at work when people bring in candy to share or donuts in the morning from other staff members. 

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2. Source of referral

a. Vonnie was not referred to take part in this assessment, she was sought out as a participant by a student the she works with. Vonnie consented to the assessment as a way to help a co-worker.

2.  Health History
   1. The reason the client is participating in this assessment is for educational purposes.
   2. Past Health History
      1. Childhood illnesses- Client reports history of chicken pox, unsure of date.
      2. Adult illnesses- Client reports gastroesophageal reflux disease, type 2    diabetes mellitus, and hypertension.  She was diagnosed with colon cancer in 1995.  She went through radiation and chemotherapy treatments and is now cancer free.

3.   Psychiatric illnesses- Client does not have any diagnosed psychiatric illnesses. 

            4.   Injuries- Client reports no history of injuries.

5. Operations- Client reports surgeries but is not sure of the dates.  Low anterior resection and hysterectomy (both at the same time), implanted port, port removal, open cholecystectomy, and tubal ligation. 
   1. Current Health Status
      1. Allergies- Client has no known drug allergies.
      2. Immunizations- Client is up to date on all of her immunizations.  She receives the flu vaccine every year, her last flu vaccine was in September 2018. 
      3. Screening tools- Client attends a yearly physical exam at her primary care Physician (PCP) where she is tested and screened for depression and alcohol misuse.  Her blood pressure is measured and recorded to help control her high blood pressure.  Her A1C is checked to help monitor her diabetes.  Weight is measured at her yearly physical, although she is supposed to keep track of it and work on losing weight throughout the year which she does not participate.  Weight loss and diet are discussed at her yearly physical.  She is screened for lipid disorders every 5 years as part of her physical as well.  Client is screened more closely than the recommended 5 years for colorectal cancer because she has a history of colon cancer.  She is screened with a colonoscopy every 3 years and has bloodwork done every year.  Client has a yearly mammogram and a pap smear to screen for cervical cancer every 3 years.  
      4. Environmental hazards- An environmental hazard is something that has the potential to cause an individual harm that is a material, a substance or a state of the surrounding environment that can harm people (White, Hall, & Johnson, 2014). 
      5. Vonnie does not have a regular exercise routine.  She states that she mostly sits each day at work or home.  On her days off she cooks and cleans and goes shopping.  She enjoys watching television and goes bowling once a week.  
      6. Vonnie reports a regular sleep schedule.  She works three days a week so she gets up at the same time on those days and also on her days off.  She reports between 8-9 hours of sleep per night.  She reports that she does not always feel well rested even with the recommended amount of sleep.
      7. Vonnie eats 2-3 meals per day.  She reports that sometimes she does not have time to eat 3 meals especially when she is at work, but she snacks throughout the day.  Vonnie always has something to eat on her in case her blood sugar drops, usually a piece of hard candy or a glucose packet.  She says that a typical day includes a breakfast bar for breakfast, a tuna melt with a side of fruit for lunch, and something quick for dinner that she picks up on her way home from work such as an Italian hoagie and French fries.  According to the Mini Nutritional Assessment (MNA) by Vellas, Garry, & Guigoz, (1999), Vonnie is normal nutritional status.
      8. Vonnie’s medications include: Tresiba subcutaneous once a day (dose dependent on blood sugar reading), Trulicity 1mg by mouth once a week, Jardiance 10mg by mouth every morning, Welchol 1.875mg by mouth twice a day with meals, Lipitor 40mg by mouth once a day in the evening, and Micardis 40mg by mouth once a day in the morning.  
      9. Vonnie reports that she does not smoke anymore.  She has a history of smoking cigarettes, 1 pack a day for 20 years.  She quit in smoking in 1998.  She denies any smokeless tobacco use.
      10. Vonnie reports that she drinks alcohol socially on rare occasions.  She drinks either a fruity mixed drink or a wine spritzer.  Mary denies use of any illicit drugs.
      11. Vonnie describes her typical day as she gets up for work around 6am.  She eats a small, quick breakfast and then drives 15 minutes to work.  She works as a secretary from 8:00am-8:30pm at a community hospital.  She takes a 45 minute lunch break and a 15 min break during the day to eat and to get off of the unit.  When she gets home she eats a small meal and watches television.  On her days off Vonnie goes shopping at Target and the grocery store, she cooks and cleans, and sometimes spends time with her daughter and her grandchild.  She sometimes helps her daughter with her grandson by picking him up from daycare or watching him while her daughter works.
      12. Computer vision syndrome is a term used to describe issues that one might complain of after sitting in front of a computer for long periods of time such as neck/shoulder pain, eye strain, and visual problems (Gowrisankaran & Sheedy, 2015).

2. Family History

   1. Mary’s father died of a heart attack when she was a young child.  Her mother died of renal disease, her mother had a history of high blood pressure and diabetes.  Mary is an only child.  Mary’s children have no signifancant past medical history problems.  A Geneogram has been included to show her history.  Mary states that she thinks her blood pressure issues are genetic and she received the genes from both her mother and father..

KEY:

E. Review of Systems and Health Promotion Activities

1. General Survey: Vonnie lives in a suburb of Pittsburgh, PA in a house with her husband, her 38-year-old son, and her dog.  Mary appears the age that she reports.  She is sitting in a chair in no distress.  She is calm and cooperative.
2. Skin, Hair, and Nails:  Vonnie’s skin in pink and warm.  Hair well kept.  No clubbing of nails.
3. Head, Face, Neck & Lymphatics:  No complaints of dizziness or drowsiness.  No pain reported in neck.  Smile symmetrical.
4. Eyes and Vision: Vonnie report that her vision is 20/20.  No complaints of floaters or dark spots.  No complaints of dry eyes or blurred vision.  Mary has an eye exam annually.
5. Ears and Hearing:  No complaints of ringing in ears or ear pain.     
6. Nose and Sinuses:  No complaints of congestion, no drainage noted.  Occasional seasonal allergies reported, Mary says she does not take anything to ease mild symptoms of itchy eyes and runny nose. 
7. Mouth and Throat:  Mouth moist, lips pink.  Teeth are her own, no dentures.  No bumps or lumps on neck.  Mary has an annual dental cleaning and dental exam.  
8. Chest, Thorax, and Lungs: No complaints of shortness of breath, no chest pain.  Mary reports that she can walk up a flight of stairs with no chest pain or shortness of breath.
9. Breasts: No complaints of tenderness or pain.  No noted problems with breasts.  Mary receives a mammogram annually.  She does not do self-examinations monthly.
10. Cardiovascular System:  Vonnie has a history of high blood pressure.  She checks her blood pressure monthly.  She takes medication to control blood pressure.  She sees her PCP quarterly to help monitor her blood pressure.
11. Peripheral Vascular:  No complaints of ankle swelling or varicose veins.  
12. Gastrointestinal:  Vonnie complains of upset stomach, she reports that sometimes when her blood sugar level is low that she gets an upset stomach.  No complaints of nausea.  
13. Urinary:  No complaints of frequency or urgency.  No reports of burning with urination. 
14. Genital, Reproductive:  Vonnie is post-menopausal.  No complaints of drainage from vagina.  Mary attends an OB/GYN check-up annually.  
15. Musculoskeletal:  No assistive devices used to ambulate.  No complaints of pain in joints or muscles.     
16. Neurological:  No complaints of dizziness.  Speech clear and appropriate.  No history of strokes or seizures.   

F. Screening Tool 

1.  Vonnie reports feeling of stress on a daily basis, therefore, the Family Inventory of Life Events and Changes (FILE) tool was used to screen for stress.  The participant is to fill out the form marking YES or NO next to the box next to the listed event/change.  The instructions state that this event/change must have happened within the last twelve months.  There is a number next in the corresponding box.  The numbers next to the boxes checked YES are calculated together for a total number.  According to the tool, totals of 750 points and up are considered high scores, and totals of 501-749 are moderate scores and the participant should be informed of their significant stress score and assisted in establishing positive coping strategies (McCubbin, Patterson, & Wilson, 1991).  Figure 1 shows the FILE assessment tool.

Figure 1. Family Inventory of Life Events and Changes (McCubbin et al., 1991).

Figure 1 Continued. Family Inventory of Life Events and Changes (McCubbin et al., 1991).

III. Components of the Physical Examination

A. Physical Assessment

1. General Survey:  Vonnie is a pleasant 57 year old female.  She is alert and orient to person, place, and time.  She is in calm and cooperative, in no apparent distress.  Her vital signs are as follows: Temperature 97.9 F temporal, radial pulse 61, blood pressure 135/74 on her right arm, O2 saturation 97% on room air, respiratory rate 14.  She is 165 cm tall and weighs 95 kg.  BMI 34.9.

2. Skin, Hair, and Nails: Skin clean, dry, pink, and warm.  Color appropriate for race.  No visible bruises or ecchymosis.  No tenting.  No edema.  Hair is thin.  No balding.  Capillary refill less than 3 seconds.  No clubbing of nails.

3. Head, Face, Neck & Lymphatic: Head appropriate size for body.  Face symmetrical, trachea midline.  No appearance of bumps or masses, none noted upon palpation.

4. Eyes and Vision:  Pupils equal, round & reactive to light & accommodation. No drainage from eyes, no redness.  No edema.  No ptosis.  Lashes and brows intact, symmetrical, and round.

5. Ears and Hearing:  No drainage from ears.  No complaints of pain upon palpation, no masses or bumps.  Both ears same shape, ears are symmetrical.  Mild swaying with Romberg test.  No deficits with hearing.   

6. Nose and Sinuses:  Nose symmetrical, no drainage from nares, nares are moist and symmetrical.  No palpable masses, no complaints of pain upon palpation.  No complaints of pain upon percussion on sinuses. 

7. Mouth and Throat:  Smile symmetrical, tongue midline.  Lips pink and moist.  Tongue and mouth moist, no lesions or ulcers present.  All teeth intact, bottom row slightly crooked.  Gums pink and moist, slight redness noted on bottom gums.  Uvula moist and midline.

8. Chest, Thorax and Lungs:  Respirations 12-16 breathes per minutes, even and non-labored.  No use of accessory muscles.  Lungs clear upon auscultation, slightly diminished in the bases.  No wheezes or rhonchi noted.

9. Breasts:  Breasts symmetrical.  Exam deferred.

10. Cardiovascular:  Apical pulse rate 62.  Regular rate and rhythm.  No murmurs, clicks or rubs.  S1 and S2 noted and strong.  No complaints of chest pain. 

11. Peripheral Vascular: Peripheral pulses all palpable.  Bilateral lower extremities +1 edema.  Bilateral hands warm and pink, capillary refill less than 3 seconds.  Bilateral feet warm and pink, capillary refill less than 3 seconds. 

12. Abdomen:  Upon inspection all quadrants are obese.  No localized enlargements noted.  Skin is pink all over.  Upon auscultation borborygmi bowel sounds are noted in all four quadrants.  Upon percussion is a dull sound all over.  Upon palpation no masses noted and no complaints of pain.

13. Urinary:  Exam deferred.

14. Genital, Reproductive:  Exam deferred.

15. Rectal:  Exam deferred.

16. Musculoskeletal:  Posture erect with head midline.  Spine and shoulders symmetrical.  Steady gait.  Limbs all the same length.  Full range of motion all limbs.  No use of assistive devices.

17. Neurological:  Alert and oriented to person, place, time, and situation.  Tongue midline, smile symmetrical.  Pupils equal, 3mm round.  Pupils reactive.  Speech is clear.  Hand grasps equal and strong.  No signs of upper extremity drift.   

4. Nursing Diagnosis 

1.  Imbalanced nutrition: More than the body requires as evidenced by obesity, BMI > 30.

2. Stress overload related to multiple co-existing stressors as evidenced by self-report of feeling stressed and the client’s score on the FILE assessment.

References

Gowrisankaran, S., & Sheedy, J. (2015). Computer vision syndrome: A review. Work, 52(2), 

303-314. doi:10.3233/WOR-152162.

McCubbin, H., & Patterson, J. (1991). FILE: Family Inventory of Life Events and Changes. In 

H.I. McCubbin & A.I. Thompson (Eds.), Family Assessment Inventories for Research and Practice (pp. 81-98). Madison, WI: The University of Wisconsin-Madison.

Pratt, M. (2013). Erikson’s seventh stage: Fostering adults’ generativity through 

intergenerational programs. Journal of Intergenerational Relationships, 11(1), 97-100. doi:10.1080/15350770.2013.754700

White, B., Hall, E., & Johnson, C. (2014). Environmental health literacy in support of social 

action: An environmental justice perspective. Journal of Environmental Health, 77(1), 24-29.

Vellas, B., Garry, P., & Guigoz, Y. (1999). Nestle nutrition services, & Nestle clinical & 

performance nutrition.