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You are to conduct a Developmentally Appropriate Comprehensive Health Assessment on any developme


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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:

    1. Provide a Complete Health History
    2. Past Medical History
    3. Past Surgical History
    4. Cultural Assessment
    5. Allergies (Environmental and All Other Allergies)
    6. Prescription and Over the Counter Medications
    7. Family Health History
    8. Complete a three-generation genogram
    9. Social History
    10. Nutritional
    11. 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)
    12. Summary of Comprehensive Health Assessment findings

Running head: COMPREHENSIVE HEALTH ASSESSMENT Comprehensive Health Assessment

 

Your Name

 

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

 

Tobacco Use

 

Drug Use

 

Domestic and Intimate Partner Violence

 

Travel History

 

Work Environment

 

Home and Psychosocial Environment

 

Hobbies and Leisure Activities

 

Stress

 

Education/Military Service

 

Economic Status

 

Pattern of Daily Living Health Maintenance Activities

 

Full review starting on page 66 Sleep

 

Exercise

 

Stress

 

Safety Equipment

 

Health Check ups Nutritional Assessment COMPREHENSIVE HEALTH ASSESSMENT Complete the following chart which comes from pgs 219-220 of your course text.

 

Anthropometric Measurements

 

Height: _____ Weight: _____ lb

 

Waist Circumference: _____ in or cm

 

Usual Body Weight: _____ Weight Change: _____

 

Body Mass Index: _____ kg/m2

 

LABORATORY DATA

 

Cholesterol: _____ mg/dL

 

Hemoglobin (Hgb): _____ g/dL

 

Triglycerides: _____ mg/dL

 

Hematocrit (Hct): ____%

 

HDL: _____ mg/dL

 

Transferrin: _____ mg/dL TIBC: _____

 

LDL: _____ mg/dL

 

mcg/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

 

information here.

 

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

 

intact.

 

-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 (pathophysiology)

 

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?

 

References

 

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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