Nursing Assignment - Health History Assessment and Physical Assessment

Running head: NURSING ASSIGNMENT
OVERVIEW OF DIFFERENT PHYSIOLOGICAL SYSTEMS
Name of the Student
Name of the University
Author Note

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Health History Assessment and Physical Assessment:
A health history assessment was done for Mrs X (hypothetical name); a 65 year old patient
diagnosed with a recent episode of Menorrhagia, but otherwise is healthy. The following
information was obtained from interview with the patient:
Demographic Data: The date of birth of Mrs X is April 1st, 1952. She was born in Houston,
Texas, where she has been living with her husband for the last 30 years. They both reside in
their own house, in a ranch. She is a Christian, and since the last 30 years, she has been
helping her husband in his cattle rearing business.
Reason for admittance: Regular checkup.
Present Illness: Mrs X companied of a recent Menorrhagia, however presently she has no
health problems. PQRST assessment not applicable in present scenario.
Perception of Health: The patient had no current physical problems, and came to the hospital
for a routine checkup. She mentioned about a recent episode of Menorrhagia, however, she
was doing well now.
Past Medical History: The patient informed that she never had any past medical problems
(apart from the recent episode of menorrhagia), and is not on any medication currently.
However, the patient has a BMI of 34.75 (obese).
Family Medical History: The patient informed that her father was diagnosed of
Hypertension and Type 2 Diabetes. Apart from that, the patient informed that there was no
other history of medical problems in her family. Her husband is also healthy, and is not on
any medication.
Review of Systems:

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Assessment of vital signs showed the following results:
Temperature: 99.6 degrees Celsius
Pulse Rate: 70 per minutes
.Blood Pressure: 110/70
Respiration 18
Oxygen Saturation Level 99%
The patient did not complain of any pain or discomfort currently.
Developmental Considerations: Since the patient was healthy, and had no current physical
ailments, no developmental consideration was noted.
Cultural Considerations: The patient is a devout catholic, and believes that she does not need
medical assistance, as she is blessed with good health. She believes that praying regularly
kept her husband and herself free from any ailments.
Psychosocial considerations: The patient seemed to be psychologically well, and showed no
signs of emotional disturbance.
Presence or absence of collaborative resources: Since the patient had no previous history of
medical conditions, no relevant details about previous health assessment was documented for
the patient. The patient’s husband is the provider of resource.
Objective Data- Physical Exam Components:
The HEENT (or Head, Eye, Ear, Nose, Throat) is one of the primary examination
done, to check for abnormalities in these systems (HEENT exam, 2017). The head (and
cranium) houses the most important part of the central nervous system, the brain, and have

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sensory organs like eyes for light perception, ears for auditory perception, tongue for
chemoreception (taste) and nose for olfactory perception (Beutel, 2017). The HEENT test
showed normal functioning in the current scenario.
HEENT assessment can be considered as the first or initial stage of any physical
examination that provides the introductory level of objective data about the patient that helps
in determining the severity of the disease that the patient is going through. Along with that it
has to be mentioned that the HEENT examination, unlike any other subjective assessment in
health care begins with inspection and then slowly proceeds towards palpation. There are
various specialized equipments associated with the HEENT examination in order to examine
the sensory responses of the patient and has crucial importance in understanding basic
sensory functioning status of the patient (HEENT Exam., 2017). The patient had normal
sensory functioning throughout as per the assessment and along with that is also needs to be
mentioned here that the patient had symmetric nose and no deviation of nasal septum as well.
In the current scenario, the functions of the thyroid and neck are normal. No
irregularities in skin pigmentation or rashes in the skin of head or neck in the neck
assessment. The Musculo-skeletal system consists of connective tissues- skeletal system,
muscular system, tendons, cartilage, joints and ligaments, the system is essential for the
stability, support and movement (Sinowatz, 2009). The patient did not show any problems
with movement, showing that the Musculo skeletal system is working fine.
As pointed before, the studied partner showed slightly lowered systolic and diastolic
pressures, and has a pulse of 70, which is within the normal range. Family health history also
revealed that her father had hypertension, which increases the chances of her developing the
same. The respiratory system consists of the lungs, trachea and larynx and the diaphragm.
The lungs are consisted of several tiny air sacs called alveoli (Gilbert-Barnes, Spicer &

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Steffensen, 2014). The partner had a normal saturation level of oxygen in blood (99%),
indicating normal functioning of respiratory system. The health partner did not have any
problems related to the unrinogental functions. Blood reports show normal levels of blood
urea and creatinine, and indicated healthy renal function. The patient had normal endocrine
function, evidenced by blood analysis of hormone levels. However, as study of family’s
medical history shows that the partner’s father had diabetes type 2, which increases her
likelihood to develop the same.
The partner did not exhibit any abnormalities in her Integumentary function or
structures. The skin was warm, with no rashes or lesions, and normal skin turgidity,
indicating healthy Integumentary system. The lymphatic system consists of the lymph
channels, lymph nodes and glands and the lymphatic fluid. The partner had health lymphatic
function, and showed no signs of infection, or lymph inflammation. The partner had normal
peripheral vascular resistance. The partner showed normal nervous activity, and had no
problems with coordination and had normal reflexes as well.
The partner did not have any issues related with the gastrointestinal functions, she had
healthy appetite, and her digestive functions were all normal. The partner had a normal and
healthy functioning of her genitourinary system. However she recently complained of heavy
and prolonged bleeding during her periods (menorrhagia).
Needs assessment and reflection:
The needs assessment is a systematic procedure that helps in identification and
reviewing the health issues that a patient is undergoing and helps in uncovering all the
potential health risks that the patient is under. In this case the needs assessment for the patient
under consideration had only discovered two health risks for the patient, menorrhagia and
diabetes, and apart from that the patient had no other possible risks associated with its

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scenario. Hence, based on the analysis of the subjective and objective data gathered from the
patient indicates at two particular health educational needs, that mainly emphasize on the
wellness of the patient. First and foremost, the most important risk for the diabetic patients is
the possibility of hyperglyceamia (Philis-Tsimikas et al., 2011). The diabetic patients must
always carry sweets or glucose supplements with themselves, so that in case of any sudden
hyperglycemic attack, they can be prepared. Most o the new diabetic patients do not have any
knowledge idea regarding the hyperglycemic attacks, their consequences and how to prevent
them. Hence, it can be considered a significant heath educational need which will help the
patient undertake a health promotional and preventative behavior. The second health
educational need that the patient had is the fact that most of the patients have no clear
understanding on the concept of diabetic foot ulcer. There are particular kinds of soft sole
footwear that are designed particularly for the diabetics so that there is minimal pressure on
the foot and each toe has equal space to spread so that the risk for diabetic foot ulcer can be
avoided. Addressing both of these health educational needs of the patient can be addressed so
that the patient can develop these preventative habits (Philis-Tsimikas et al., 2011).
The reflection assignment helped tremendously in my own professional development.
It has to be mentioned in this context that the physical assessment of the patient is one of the
most preliminary steps of providing care to the patients and is a clinical task that every
nursing professional has to perform in their professional career. This reflective assignment
helped me gain knowledge and understanding on how to health assessment examinations and
how to collect and analyze subjective and objective data on the patient. It has to be mentioned
in this context that these communication based assignment are often associated with many
challenges or barriers that hinder effective channeling of information. In this case, there had
been no significant communication barrier on the other hand; the assessment program
completed successfully with any unanticipated challenges. There had been a few incidences o

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confusion in the patient regarding the understanding of the different activities that the patient
had to undergo during the entire process of assessment. Although, one limitation for this
assessment procedure is the fact that the patient could not provide much details on the past
medical history of how and when she acquired diabetes and any long term effect of her
menorrhagia which would have facilitated a more specific and patient centred diagnosis. In th
future instances, I would ensure to develop a comforting mutually respectful relationship with
the patient so that the patient feels comfortable and can share personal preferences or
grievances more easily with me. Along with that I would also ensure to explain the different
assessment procedures and the different activities associated with it so that there is no
confusion or misunderstanding in the patient and they can participate equally in the procedure
for optimal results.

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