You are to conduct a Developmentally Appropriate Comprehensive Health Assessment on any developmental group you choose. Choose one of the following development ages:
The Developmentally Appropriate Comprehensive Health Assessment should include each of the following subheadings in the assessment:
- Provide a Complete Health History
- Past Medical History
- Past Surgical History
- Cultural Assessment
- Allergies (Environmental and All Other Allergies)
- Prescription and Over the Counter Medications
- Family Health History
- Complete a three-generation genogram
- Social History
- Review of Systems (ENAP Format: E = examination component, N = normal assessment finding, A = common abnormal assessment for physical examination, P = pathophysiology of the abnormal findings)
- Summary of Comprehensive Health Assessment findings
Running head: COMPREHENSIVE HEALTH ASSESSMENT Comprehensive Health Assessment
Rasmussen College Author Note
This paper is being submitted on Month XX, 2016, for Instructor?s Name NUR3177
Health Assessment course. 1 COMPREHENSIVE HEALTH ASSESSMENT 2 Complete Health History
Health histories are discussed in your text on page 44. Introduce your client. Please use
initials or a ?fake? name if you are doing this paper on a real person. On page 46, the text
discusses basic information to collect from your client. Where does your client live (only a city
and state, do not specifics, like street address or other identifying information)? Lived there all
his/her life? Career? General demeanor and appearance? Just need to include some basic
demographic information. No need to do a chief complaint or other items listed after page 46.
This section can be very short (but at least 3-5 sentences). If you have a pediatric client, be sure
to also review Chapter 25 when completing this assessment. For example, the health history
requires additional notes (see p. 926) Developmental Stage Assessment
In this section, identify what developmental stage your client is in based on Erikson?s
developmental stages. (Don?t forget citation) You will find information on Erikson?s stages in
your e-book on pages 93-94. Please discuss specifically if your client has achieved their current
stage or not. Support your decision from your assessment of the patient and detail what supports
this conclusion. Medical History
See page 50 of your e-book for help writing this section. Please bullet point each illness,
include brief summary of illness based on questions provided on p 50. Please see example: HTN- Diagnosed in 2012 by PCP who is currently managing with medications, dietary
changes, and exercise. Well managed, denies difficulty with medications, but does not
follow prescribed diet or exercise routinely. Has never been hospitalized or experienced
complications Surgical History COMPREHENSIVE HEALTH ASSESSMENT 3 See page 50, bullet point surgeries with additional information included as stated on p. 50 Allergies
-This section can be in bullet format if there are many allergies. Don?t forget to include
medication, latex, foods and environmental allergens along with patient reaction. This is also
detailed on p. 50 Prescription and Over-the-Counter Prescriptions
-This section can also be bulleted.
-Include the drug name, dosage and frequency.
-Don?t forget to include why he/she is on the medication. Cultural Assessment
Please use Chapter 5 and the EACAT tool found in your e-book on page 143 (within Chp.
5) to write this section. Document concisely in third person. An example of how to document is
on page 145. Family Health History
List of familial disease, may bullet point. At a minimum, should contain age and health
status of spouse, children, siblings, and patient?s parents. Preferred is to expand to patient?s
grandparents, aunts, and uncles. See page 54-56 of your e-book for help with this session. Three Generation Genogram
Please see page 56 for an example of a three generation genogram. Your genogram can be
a separate file (i.e. power point presentation). It does not need to be embedded into your paper.
You can also do it by hand and scan it in/take a picture of it and upload it with this paper. Social (including psychosocial) History
Information for this section can be found on pages 57-67 of your e-book. Please elaborate
on each of the following as described on pages 57-67 your e-book. Write concisely in third COMPREHENSIVE HEALTH ASSESSMENT 4 person. Do not write out questions asked. Example: Alcohol: Drinks about 2 beers per week,
pattern has not changed. First exposure was 20 yrs of age. Denies drinking alone, driving, and
has never lost memory or blacked out.
(note- if assessment is of child, make sure and interview parental/caregiver to answer the
questions. You will also want to know potential exposures to the children from the parent (use of
alcohol, tobacco, domestic violence, work exposures from parental clothing) Alcohol Use
Domestic and Intimate Partner Violence
Home and Psychosocial Environment
Hobbies and Leisure Activities
Pattern of Daily Living Health Maintenance Activities
Full review starting on page 66 Sleep
Health Check ups Nutritional Assessment COMPREHENSIVE HEALTH ASSESSMENT Complete the following chart which comes from pgs 219-220 of your course text.
Height: _____ Weight: _____ lb
Waist Circumference: _____ in or cm
Usual Body Weight: _____ Weight Change: _____
Body Mass Index: _____ kg/m2
Cholesterol: _____ mg/dL
Hemoglobin (Hgb): _____ g/dL
Triglycerides: _____ mg/dL
Hematocrit (Hct): ____%
HDL: _____ mg/dL
Transferrin: _____ mg/dL TIBC: _____
LDL: _____ mg/dL
Iron: _____ mcg/dL
Glucose: _____ mg/Dl
Vitamin D: _____ ng/mL
HbA1c: _____ %
Vitamin B12: _____ pg/mL
Folic Acid: _____ ng/mL
Albumin: _____ g/dL
Part 1: General Diet Information Use p.220, table 7-7 to complete Part 1. Summarize responses and document collected
Part 2: Food Intake history (24-Hour Recall) Review of Systems
This will collect both patient interview (subjective data) and physical exam (objective
data) for each system. For each of the following systems, start with the ROS (full review of
systems on p.70) than complete an ENAP (p.69) for each. 1) General Survey 2) Skin, Hair &
Nails 3) Head, Neck, Lymphatic 4) EENT 5) Thorax & Lung 6) Heart and Peripheral
Vasculature 7) Abdomen 8) Musculoskeletal 9) Mental Status & Neurological
Please single space as shown below. Here is an example of the system ?skin, hair, & nails.? The
following should be completed on each of the 9 systems listed above:
Skin, Hair and Nails:
-ROS (p 70): Denies Rashes, itching, changes in skin pigmentation, ecchymosis, change in color
or size of mole, sores, lumps, dry or moist skin, pruritus, change in skin texture, odors, excessive 5 COMPREHENSIVE HEALTH ASSESSMENT 6 sweating, acne, hives, warts, eczema, psoriasis. Sun exposure occurs when running errands, daily
jogging in the afternoon and attending sporting events use of sunscreen. Wears hats, usually does
not apply any sunscreen. Denies changes in nails, no splitting or cracking. Denies excessive hair
or hair loss, colors hair monthly, no scalp lesions.
-E: I will observe/inspect for color, bleeding, ecchymosis, vascularity, lesions, rashes,
pigmentation changes, moles or tattoos. I will palpate for moisture, temperature, tenderness,
texture, turgor, and edema. Inspect hair for color, distribution and palpate for texture. Inspect nails
for color, shape, configuration, cracking, thickening, or discoloration. Palpate nails for texture
-N: Color, uniform, even; No areas of ecchymosis, bleeding, lesions, or rashes. Scattered moles
present less than 2mm in size with regular borders. Skin dry, warm and equal bilaterally; texture
smooth and even; turgor with immediate return once released; edema, not-present in all 4
extremities, no tenderness with palpation. Nail beds pink, nails smooth and intact, without
spooning, discoloration, cracking or thickening. Hair smooth, and evenly distributed, scalp
-A: 8 bright red, circumscribed, and flat areas, about 3mm each on torso
-P: Cherry angiomas are most often on the trunk of the body. The cause is unknown and they are
considered pathologically insignificant (Estes, 2014) (For the Pathophysiology, ?P,? provide
Explanation of ENAP format (p. 69). ?E? -Examination component, what will physically be examined. To write this
component, follow the system specific videos provided in course modules 2-5 as your
guide. Currently, there is no abdominal assessment video posted, please use p.1040 as your guide.
?N? -Normal assessment findings based on your exam of the client. Document all of
your findings from your client exam that were normal, expected findings. NOTE: Do not
use words like ?good? or ?normal? in your documentation. Instead write what you
observe. For ex: ?good capillary refill? versus ?capillary refill less than 2 seconds? (see
p.71, Table 3-4) COMPREHENSIVE HEALTH ASSESSMENT 7 ?A? -Abnormal assessment findings based on your exam of the client. Document all of
your findings from your client exam that were abnormal, unexpected findings. If none, document ?None?
?P? explains the pathophysiology behind any documented abnormal findings. Here you
will explain the pathophysiology of any abnormal assessment you have documented. If
there were no abnormal findings for the system assessed, document ?None? here. Summary
Summarize your findings of the patient. What is the pertinent information that you will
want to report and/or follow-up on? What are issues needing immediate attention? Any findings
that put the patient at risk? Any indication that the patient is ready for enhanced health promotion
in a specific area? This section should almost be an introduction to your care plan that you will
be creating in week 10 from this assessment (but not your actual care plan please). What were the
highlights of the assessment?
The final portion of the paper is the references section. The references section gives
complete information about all of the sources that are cited in the paper. For Rasmussen papers,
the reference section follows APA formatting rules. For more information on how to write a paper
and use proper APA citation and formatting, please see http://guides.rasmussen.edu/apa. For
information on references in APA style, see http://rasmussen.libanswers.com/a.php?qid=168857
Don?t forget to utilize citation within this document.
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