HNN114 HEALTH ASSESSMENT.

Running head: HNN114 HEALTH ASSESSMENT
1
HNN114 health assessment
Student’s Name
Institutional Affiliation

HNN114 HEALTH ASSESSMENT 2
HNN114 Health Assessment
Introduction
Health assessment is an important aspect of clinical practice. Patient assessment enables
nurses to determine the core health issue but also be in a position to recommend the best
medication. This paper will focus on a case study presented of a patient who fell from work who
is under assessment.
Part A
To begin with, the following table has outlined the subjective and objective data gathered
from the given scenario.
Subjective Data Objective Data
48 years old, male
Nausea/Vomiting Risk of obesity
Upper right quadrant abdominal
pain 3/10
Tissue perfusion
Dizziness Jaundice
History of TIA-Transient ischemic
attack
Cholecystitis
No known allergies Tachycardia: 105
Feels thirsty Hypertension: 150/80 mmHg
Sweating Tachypnea: 25
Dry mouth Febrile: 37.8
Feeling exhausted and weak Urinalysis-Bilirubin and Ketones Positive
Feeling awful Dehydration
malnutrition
Body system approach
In the following table, the above health assessment framework is outlined by arranging
the health data collected from the scenario.

HNN114 HEALTH ASSESSMENT 3
Area for Assessment Normal Range of Findings Abnormal Findings
Neurological and sensory
system
Facial expression – smile
Speech
Symmetry
Body movements
Hearing
Level of consciousness – alert,
oriented
Eye contact
Tongue movement
Febrile – 37.8oC
Upper right quadrant
abdominal pain – 4/10
Mental health Grooming and hygiene Mood – depression due to
illness
Cardiovascular system Herat sounds –N/A
Peripheral pulses – N/A
Capillary refill – N/A
Appearance and temperature
of extremities – N/A
Increased Heart rate – 105 per
minute
Hypotension 150/80 mmHg
TIA- Transient Ischemic
Attack
Respiratory system Tactile Fremitus
Oxygenation without aids
No obstructions in upper air
way
Breathing heavily
Tachypnoea – 25 per minute
Gastrointestinal system N/A Dehydration
Nausea and vomiting
Cholecystitis
Endocrine system N/A Risk of diabetes – BMI
appears to be a bit above the
ideal range
Renal/bladder Urinary elimination patterns –
route: urethra
Control – continence
Urinalysis positive for
bilirubin and ketones
Skin, hair, nails Skin pigmentation
Hair and nails – intact smooth,
shape round, natural
Yellowing in nails, tongue,
and palms due to jaundice
Musculoskeletal Extremities: normal size,
length, shape, symmetry
Joints: symmetry, active and
passive mobility
Rest and activity level pattern:
usually fit and active
N/A
Reproductive system Hereditary and genetic factor
– N/A
Breasts – N/A
Sexual activity patterns – N/A
N/A
Psychosocial General impression: overall