Health History and Examination Health Assessment of the Head

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

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Student Name:

Date: August 27^th, 2014

Client/Patient Initials: LLB	Sex: Female	Age: 80
Occupation of Client/Patient: Domestic Engineer
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): Patient denies any head injuries, headaches, convulsions, tremors, numbness, tingling, difficulty speaking or swallowingPatient denies taking any medication in correlation to her neurological systemPatient states, “When I get up sudden I have to wait a moment because I get dizzy.”
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient denies any problems in the head and neck but states, “When I travel I bring a special pillow because my neck gets sore on the wrong pillows.” Patient denies taking medication.
Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications): Patient states she has a history of dry macular degeneration and it is being well controlled. Patient uses special eye drops for her eye disease. Wears corrective lenses. Admits to blurred vision occasionally. Negative glaucoma testing 02/15/2014Eye surgery in relation to the macular degeneration 08/13/2013
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): Patient denies any ear problemsLast eye infection was over 10 years ago. No discharge noted from ears
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): Lips pink, mucous membranes pink and moistNo discharge or foul odor notedNo history of nosebleeds, bleeding gums, allergies or surgeries on nose, mouth or throat. Lymph nodes barely palpablePatient had 4 wisdom teeth removed at age 20Patient states she flosses daily, and brushes her teeth twice a day with sensodine. No dentures notedNo missing teeth.
Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): Patient’s skin is flawless (I wish I age as beautiful as my grandmother). Patient denies any skin disease, any changes in skin, excessive dryness, moisture, itching, any bruising, rashesPatient has thinning hair. Patient states, “My hair started thinking in my late 50s, now I keep it short so people don’t notice all the hair I’ve lost.”Patient moisturizes skin twice a day and reapplies with sun exposure. Patient uses protective clothing and hats in the sun Patient has an ingrown nail on her left big toe that causes discomfort and goes to a podiatrist to get it looked. Patient does her pedicure every two weeks to have the nail trimmed by professionals.
Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications): Patient denies any breast problemsLast mammogram 06/07/2014Monthly self breast exam No medications Patient states, “They just aren’t as perky as they use to be.”
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): No complaints of leg or ankle pain, cramps, swellingNo swollen glandsNo medication Patient does have varicose veins in legs and arms
Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications): No cardiovascular problems noted Patient states she takes a baby aspirin daily as prescribed by her doctor Patient walks daily for a minimum of 30 minutes. No self or family history of heart disease
Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications): No cough, SOB or pain while breathing No history of lung diseasePast smoker of 10 years, Quit when she was 40 years old. Yearly flu shot Pneumococcal vaccine within the last 5 years Last chest X RAY 04/08/2014 Negative findings NO medications
Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications): Joint and back pain noted after long days working at the Church and in the garden, particularly when in one position for long periods. Limited range of motion in rotator cuff , performs exercises as instructed by physical therapist No accident or trauma to bones Performs activities of daily living independently, just slower.
Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications): Patient has regular daily bowel movements, takes fiber to helpNo change in appetiteNo difficulty swallowing foodsHistory of diverticulosis, avoids nuts and seeds Occasional antacid after too much Italian food
Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, suprapubic region or low back): Has urinary Incontinence when laughing or coughing Urine clear, Patient states, “I drink 8-12 glasses of water a day.”Past history in her 40s of urinary tract infections and yeast infections
Physical Examination (Comprehensive examination of each system. Record findings.)
Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): Limited range of motion in right armDetects cold and warm touches as well as sensations Able to distinguish smellsEOM intact, pupils reactive to light6 cardinal fields of vision Lifts eye brows, demonstrated facial movements Able to distinguish taste Able to hear sounds Able to swallow, gag reflex in place, moves tongue without difficultyAble to shrug shoulders and ROM of neck
Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland): Lymph node palpable, non tender or swollen Trachea midline
Eyes *(test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus):* EOM intact Sclera clear 6 cardinal fields of gaze Known history of dry macular degeneration, unable to detect abnormality of visual assessment.
Ears *(inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity):* No drainage noted in ears, minimal wax seen in ears Tympanic membrane seen, pink non ruptured Sounds able to be detected
Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat): Nose patent, smells detected Sinus non swollen Carotid palpable
Skin, Hair and Nails *(inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach self-examination techniques):* Skin smooth, non elasticCool to touch Mucus membranes moist No lesions on scalp Thinning hairNails short and clean, in growing toenail left toe
Breasts and Axilla (deferred for purpose of class assignment)
Peripheral Vascular and Lymphatic System *(inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps):* Brachial pulses palpable bilaterally +2Arms symmetric Varicose veins on legs Pedal pulses palpable bilaterally +2No lumps, swelling or discoloration
Cardiovascular System *(inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S₁ and S₂, any extra heart sounds, murmur):* Carotid arteries palpable JVD –Apical pulses heard, S1 S2 noted HR 80, NSR
Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds): Thoracic cage demonstrates symmetrical breath movements Trachea midline No abnormal breath sounds Tactile fremitus felt on palpation
Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion): No swelling, mass or deformity noted on spine. Rotator cuff pain when rotated Limited range of motion in right hand related to that Shoulders even, squaredNo deformity noted in hands, feet, hipsActive ROM in legs.
Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness): Abdomen soft, flat, symmetric Umbilicus shallow and clean Bowel sounds active x4No tenderness No enlarged organs palpated Negative rebound tenderness
Genitourinary System (deferred for purpose of this class)
FHP Assessment
Cognitive-Perceptual Pattern: Patient needs corrective lensesHas dry macular degenerationOccasionally back, neck and joint pain from prolonged standing Joint pain related to rotor cuff injury, patient was instructed on exercises to help by physical therapist.
Nutritional-Metabolic Pattern: Patient east 4-5 small meals a day, cuts out heavy meals at nightOne glass of wine at dinner, 1-2 nights a weekFiber is increasedNo seeds and nuts related to diverticulosis
Sexuality-Reproductive Pattern: Patient has not have sex for 10+ years, satisfied with the current situationMenopause at age 47
Pattern of Elimination: Daily bowel movements Has stress incontinence when coughing or laughing Urinary frequency No diseases
Pattern of Activity and Exercise: Works in her garden 3 times a week Participates in church activities 6 days a week Drives but has limited vision at night
Pattern of Sleep and Rest: Sleeps 5-6 hours a night Takes 1 hour nap in afternoon Feels rested when she wakes up in the morning.
Pattern of Self-Perception and Self-Concept: Loves herself as she is, uses minimal make up. Has beautiful skin Is very religious and views herself as living a humble life She is grateful for life and all she has been blessed with
Summarize Your Findings (Use format that provides logical progression of assessment.)
Situation (reason for seeking care, patient statements): Author: Julia Bowman Marr, RN Date: August 27^th, 2014 Situation: Health History and Screening Interview
Background (health and family history, recent observations): Face to face interview conducted in patient’s living room, optimal patient privacy given. The patient is an 80 year old female who has a history of diverticulosis, dry macular degeneration, injured rotator cuff and frequent stress incontinence. The patient has had yearly physical checkups. Her most recent surgery was eye surgery performed on 8/13/2013. No complaints at this time, just a scheduled Health History & Screening.
Assessment (assessment of health state or problems, nursing diagnosis): Patient lives an active lifestyle. She controls her macular degeneration with medication, frequent checkups and surgery. Patient has stress incontinence and seeks further education and instruction. Pain in joints restricts patient from church activities sometimes. She sees a physical therapist. When asked to demonstrate exercise techniques given to do daily by physical therapist she is unable to demonstrate all. Nursing Diagnosis: *Wellness:* Effective Therapeutic Regimen Management as evidenced by thorough management of macular degeneration. *Actual:* Altered Urinary Elimination; Stress Incontinence as evidenced by frequent involuntary urinary elimination when coughing and laughing.
Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education): In regards to patient’s stress incontinence, kegel exercises were explained to help with the incontinence. Hygienic recommendations were also given in regards to keeping dry and avoiding infections. Patient verbalized understanding. Patient demonstrated complete understanding of eye care. Next eye appointment is in 2 months. Physician phone number easily accessible in case of emergency.

Reference

National Nurse Leadership Council. 2014. Retrieved from http://www.ihs.gov/NNLC/documents/resources/SBARTEMPLATE.pdf

Weber, J. R. (2005). Nurses’ Handbook of Health Assessment, 5th Edition. Philadelphia: Lippincott Williams & Wilkins

Health History and Examination Health Assessment of the Head

Health History and Examination Health Assessment of the Head

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