Middle Age Adult Health History Assignment Guidelines N315 Fall 2008

Middle Age Adult Health History Assignment Guidelines N315 Fall 2013 Submit no later than Tuesday, October 1st, 2013 at the beginning of lecture. For every day (including weekend days) the assignment is late, 5 points will be deducted from the total score. You must have Health History Score Sheet attached to assignment when handing in to lab instructor. Conduct a health history using the entire Complete Health History given in the Middle Age Adult Assignment. Use this form, posted on Blackboard- do not substitute. Use professional terminology, correct spelling, and type or write neatly in ink, or use the downloaded form with typed, bolded responses (Do not reformat the history if you choose to do this- it should look like the original). You must submit a paper copy on the date and time assigned. Invite a relative, friend, or acquaintance who is between 40-64 years old to participate in practicing a comprehensive health history. Let them know that this will take about 1 1 hours. It should be a face-to-face interview not a telephone interview if possible; you will get different data if you use the phone. You should inform the person you select that this is a practice history, that it is not diagnostic, and that you cannot treat any problems discussed; it is only for your educational purposes. Obtain the participants phone number and let him/her know that the lab instructor may call to ask about their experience of the interview with you. Phone number should be entered on assignment form. Identify the historian by first name only to protect confidentiality. You should not make judgments. Do not say normal or good unless the patient actually states this and you have it in quotation marks. Hospitalizations and operations as well as childhood illnesses should include description and dates if patient can remember. Genograms should be complete with key and should correlate with family history. If patient does not have a particular problem in the area document patient "denies" or "denies all possible complaints listed. Do not leave areas blank. Do not write normal, and do not write not applicable (N/A) unless it is truly not possible. (Example: questions related to the other gender) For ALL problems or abnormal findings: Place a star (*) on the history in the left margin, and fully describe ALL problems or abnormal findings. EVERY problem should be followed up on the separate problem sheet using O (Onset), P (Provocative or Palliative), Q (Quality or Quantity), R (Region or Radiation), S (Severity), T (Timing), and U (Patients understanding of the problem). Use the * starred areas as the basis for formulating your Nursing Diagnoses. Make a list of all of client's strengths and all areas for improvement. Formulate and prioritize 3 nursing diagnoses, using your nursing diagnosis text (Carpenito) as a guide (These are NANDA diagnoses). Use the areas that you starred in the Health History or in areas for improvement to choose and prioritize the 3 main areas of problems or potential problems for your patient. Give evidence that supports each Nursing Diagnosis, and give your rationale for prioritizing as you did. (What was the evidence that this needed to be one of the 3 main diagnoses, and why did you put it as your top, second or third priority?) Use your Carpenito to formulate this section into NANDA approved nursing diagnoses. You should be making connections between pattern areas. For example if a patient states they have asthma that also may affect a number of Nursing diagnoses, not just one. (Example: may effect exercise, allergies or sleep) List 2 references (may use Carpenito, Bates and/or Weber) that you use as guides for making Nursing Diagnoses and prioritizing. University of Massachusetts, Amherst, MassachusettsSchool of NursingMidlife Complete Health History Special guidelines: Please * star all abnormal responses in the left margin of the form. If you note any abnormal response, follow up with branching questions and use mnemonic OPQRSTU O (Onset). P (Provocative or Palliative), Q (Quality or Quantity), R (Region or Radiation), S (Severity), T (Timing), and U (Patients understanding of the problem). Use the * starred areas to formulate your Nursing Diagnoses. You should not leave any areas blank. Please note: this is a general Health History. Health History questions should be adapted for each client based on gender, developmental needs, special needs and cultural considerations..Student Name____________________________________________ 55 Total Possible Points: _________________Biographical Data: 2 Possible Points_______

Clients first name: Theresa Phone number: 603-496-5047 Date of birth: 09/11/1957

Birthplace: Concord, NHMarital status (single, married, partnered, divorced)) Married Age: 56

Race/ethnicity: Caucasian Occupation (current &/or past):Loss Prevention Manager/ Retail store ManagerGender: Female

Language(s) spoken: English Religion if any: Catholic Advanced directives (examples: living will, health care proxy, etc.): None

Do you have health insurance? YES NO If you have health insurance is it adequate? _______________________________-Allergies: 2 Possible Points_______Do you have any allergies to: If yes, describe the reaction: What do you do for your allergies?Medications?YESNO

Latex?YESNO

Environmental substances?YESNOPollen, ragweed. Pt states: itchy and runny nose.Pt states: I take OTC allergy medication Alavert.

Food?YESNO

Current Medications: 3 Possible Points_______

What medications are you taking?Medication name (include prescribed, herbs, vitamins, hormones & over the counter):Purpose of medication?What is the strength and how often do you take?Any side effects or difficulties?

Sumatriptan Migraine 500 mg 4x total a day during episodic migraine Sleepiness

Equate Brand

Multivitamin Bone & heart health, immune health & energy metabolism, reproductive system and healthy skin.1 tablet a day Pt states:No side effects.

Iron supplement 1 tablet a day Pt states:No side effects.

Natural sleep aid Insomnia 1 tablet every might Pt states:No side effects.

Functional Health Patterns:HEALTH PERCEPTION HEALTH MANAGEMENT PATTERNS: 7 Possible Points_______Client's Perception of Health: Describe your health:Pt states: My health is good.

How would you rate your health on a scale of 0-10 (10 is excellent)?Now: 95 years ago? 7How do you expect to rate your health in 5 years? 8

What do you believe causes health and illness?Pt states: Poor eating habit.

Have you had any past health problems? (Include illnesses, accidents, injuries, childhood health care problems, hospitalizations, and operations with dates)Migraine

Lymph Node on right shoulder area removed 1997

C-section 11/92

Infected lymph node removed 09/2012

Heat exhaustion 08/2013

Do you have any current health problems? If so, describe:Migraine since 1996

Insomnia since 1993

Allergies ( seasonal allergies, pollen and ragweed)

If you have any current health care problems, please answer the questions below: (Reminder: OPQRSTU all positive findings) What do you believe caused your health problem? How do you believe your health problem should be treated? How has this affected your normal daily activities? Are you having any difficulties in caring for yourself or others at home because of this health problem? If yes, explainPt states: Migraine runs in the family, and migraine also stress related.

Pt states: Migraine should be treated with medications, and change of environment (dark quite area).

Pt states: I have to stop my activities and lay down. It has to be quite and dark.

Pt has no difficulty in caring for themselves and others.

Health Management and HabitsWhat do you do when you have a health problem?Depending on severity pt states: Manageable by medication or change of environment. If severe pt states: Physician visit.

When do you seek nursing or medical advice?Pt states: When s/s become worse or current OTC dont work.

How often do you usually go for professional exams: Physical exam: Dental exam: Gynecology exam and pap smear if female:Once a year

Twice a year

Once a year

Have you ever had the following: YES NO Date of last screening?What were the results?

Mammogram?09/12/2013Negative

Blood pressure screening?120/70

Colonoscopy?

Other? EKG 06/20/2013Normal, no unexpected findings.

What activities do you believe keep you healthy? Contribute to illness? Pt states: Physical activities such as walking and exercise will keep her healthy. No drinking or smoking. Pt states: Eating habits contribute to illness.

Do you have any cultural healing practices that you engage in?Pt states: No.

Do you use any complementary health care therapies?Pt states: No.

Do you perform self exams (blood pressure, breast, testicular? If so, please describe.Pt states: Self breast exam.

Do you use: YES NO If yes, describe the amount and time used.

Alcohol?

Tobacco?

Drugs?

Are you exposed to pollutants/ toxins?Describe:

When were your last immunizations?2008Are all of your immunizations up to date? (ex: Tetanus, Hep B, Annual Flu vaccine)YESNO

Have you had a pneumonia vaccine? (recommended for people over 65 or with a serious chronic illness)Date:

Accident Prevention/Safety/ EnvironmentYESNO

Do you always wear your seatbelt when in a car?

Do you either avoid loud noises (including loud music) or wear hearing protection when necessary?

Is the place where you live equipped with these safety measures:

Slip resistant surface in the bathtub or shower?

Grab bars or handles in the bathtub or shower?

Slide resistant rugs?

Is your total living space adequate?

Do you have adequate clean water?

Do you have adequate light and electricity?

Do you have adequate heat?

Do you have adequate ventilation? (windows, fans, air conditioning)

Do you have adequate working smoke detectors in your living space?

Are there hazardous substances in your home? (asbestos, lead, large used batteries, poisons)

Do you have accessibility to 911 emergency services? (police, fire, ambulance)

Do you have posted your areas fire department, police department and emergency numbers?

Compliance with Prescribed Medications and Treatments (if applicable)Have you been able to take medications, if prescribed by your health provider?

If not, what prevented you from taking the medications?

Have you been able to follow through with nursing/ medical treatment (ex. diet, exercise) if prescribed?

If not, what prevented you from following through with such treatments?

NUTRITIONAL-METABOLIC PATTERN 6 Possible Points_______Dietary and Fluid IntakeDescribe the type and amount of food and fluid you eat and drink on an average day:

Breakfast:Banana, 1 cup coffee, 1 cup grapes, 8 ounce yoghurt.

Lunch:Ham and turkey sandwich on whole wheat, cheese stick and jello.

Supper:Chicken or steak tip, brown rice.

Snacks: 2 Graham crackers and 1 cup of strawberries.

How many servings did you have yesterday?None1 or 23 or 45 or more

Fruits, vegetables, greens

Protein foods such as meats, fish, poultry, beans, soy products, eggs, cheese, milk

Calcium rich foods like low fat or nonfat milk, yogurt and cheese

Grains like Rice, pasta, potato, bread, and cereals

Iron rich foods like lean meats, beans, or iron supplemented orange juice and iron enriched cereals

High fat foods like ice cream, cookies, pastries, donuts, pie and potato or corn chips, fatty meats (hot dogs, bologna, salami, bacon, sausage), fried foods, whole milk, regular cheese, cream and butter or margarine

YES NODo you have enough economic means to purchase food?

Who buys the food? Pt buys food.Who cooks your meals? Pt cooks meal

Do cultural beliefs and practices influence your diet?

Describe:

Are you on a special diet or do you have any dietary restrictions?

Describe:

YESNO

Have you ever gone on a weight reducing diet?

If yes, how often? 4 out of the 12months For how long? 4 months

If yes, are you on a weight reducing diet now?

If yes, describe the diet method(s) you use: (examples: food restriction, calorie or fat restriction, increased activity or exercise, liquid meal replacement, starvation, diuretic, laxative, enema, vomiting)Pt states: before no carbs in diet, but now low carb.

What is your desired weight? 160 lbs. What is your current weight? 178. lbs

Any recent increase in appetite? (If so, describe: )

Any recent decrease in appetite? (If so, describe: )

Have you had a sore throat, sore tongue, sore teeth and/or sore gums recently?

If yes, describe:

Do you have a history of, or are you experiencing any:

Abdominal pain?

Nausea or vomiting?

Food intolerance?

Abdominal distention?

Burping?

Heartburn?

Vomiting blood?

Other intestinal problems?

If yes to any of the above, describe:

Have you had any colon screening tests (colonoscopy, sigmoidoscopy, stool tested for blood)?

If yes to any of the above, describe:

Condition of Skin, Hair and NailsYESNO

Describe the condition of your skin Pt states: My skin most of the time moist.

How well and how quickly does your skin heal? Pt states: My skin heals pretty quickly.

Do you have any skin rashes or lesions? If so, describe.

Have you had any changes in color, size or shape of any moles in the past or present? If so, describe.

How much are you exposed to the sun?

Do you use sunscreen?

Describe the condition of your hair and nails

Have you had difficulty with scalp itching or sores? If yes, describe

Do you use any special hair or scalp care products? If yes, describe

Have you noticed any changes in your nails? (color, cracking, shape, lines, loss) If yes, describe.

ELIMINATION PATTERN 3 Possible Points_______Bowel HabitsYESNO

How frequent are your bowel movements? Pt states: Daily 1-2 times an average.

What is the color and consistency of your stools? Pt states: Brown and not hard.

Do you have any discomfort with your bowel movements? If yes, describe.

Have there been any recent changes in frequency, color or character of your stools? If yes, describe.

Do you have or have you had any constipation, diarrhea, black stool, flatulence, incontinence, hemorrhoids, rectal bleeding, rectal fistula (or other)? If yes, describe.

Have you ever had bowel surgery? If yes, describe.

Do you use laxatives, enemas, or suppositories?

If so, describe what kind and how often you use them if you do.

(space to describe any abnormal findings from the previous questions)

Bladder HabitsHow frequently do you urinate?Pt states: 4 to 5 times a day.

What is the amount and color of your urine?Pt states: Pale yellow.

Do you have problems with the following: YES NO If yes, describe.

Pain on urination (dysuria)?

Nocturia (urination at night)?

Polyuria?

Oliguria?

Blood in urine?

Cloudy urine?

Foul smelling urine?

Difficulty starting urination?

Incontinence?

Urgency?

History of bladder or urinary tract infections?

Do you use any measures to prevent urinary tract infections (UTIs)?

Do you have pain in back, groin, flank or suprapubic areas?Pt states: Pain in the lower left groin area.

Do you perform Kegel exersizes?Pt states: Kegel exercise, in standing.

ACTIVITY-EXERCISE PATTERN 5 Possible Points_______Activities of Daily LivingDescribe your activities during a typical week day.Include hygiene, cooking, shopping, work, eating, house and yard, and school activities, activities with family and friends, and other self-care activities)Hygiene: Shower daily

Walking: 1 mile every day

Shopping: 15 min an average

Yard work: 1 hour a day

Activities with friends & family: 10 hours a week

How satisfied are you with these activities

Do you have problems with the following: YES NO If yes, describe.

Bathing, dressing, eating?

Meal preparation?

Shopping, housekeeping, paying bills, etc?

Does anyone help you with these self care activities?Husband and son

Do you use any special devices to help with your activities?

Does your current physical health affect any of these activities?

Do you have any dyspnea, shortness of breath, palpations, chest pain, pain, stiffness, weakness, muscle pain, and/or coordination problems?

Do you have any history of muscle disorders, arthritis, gout, back pain, disc problems joint pain, stiffness, swelling, deformity, limited movement, paralysis and/or crepitus?

Do you have any peripheral vascular problems for example coldness, numbness, tingling, swelling in legs & feet, color changes in legs & feet, varicose veins, thrombophlebitis and/or intermittent claudication?

Leisure, exercise and work activities YES NO Describe.

Describe the leisure activities you enjoy and how often you are able to do them.Going to the movies once a month, walking daily at work, reading daily, swimming during the summer months.

Has your health affected your ability to enjoy your leisure activities?

Describe those activities that you believe give you exercise?Pt states: Walking at work, unloading a truck at work and swimming.

How often are you able to do this type of exercise?Pt states: Daily.

Is there anything that interferes with your exercise routine?

If employed describe what you do to make a livingPt states: I work in the retail.

Has your employment affected your health?Pt states: Migraine related to stress.

Has your health affected your ability to work?

SLEEP-REST PATTERN 2 Possible Points_______Sleep HabitsDescribe your usual sleeping routine and time at home.

Pt states: Bedtime 10pm, wake up 7am. Pt states: I watch TV before bedtime.

How would you rate the quality of your sleep on a scale of 1-10 (10 being the best)?6

Do you have problems with the following: YES NO If yes, describe.

Difficulty falling asleep?

Remaining asleep?Pt states: I wake up 3 times a night, and I am awake for 2-3 hrs.

Does anything help you fall asleep and/or fall back to sleep? (Examples: lots of exercise during the day, medications, reading, TV, relaxation techniques, music, milk, alcohol).

Pt states: TV and medication (sleep aid).

Do you ever feel fatigued after a sleep period?Pt states: I feel fatigued and agitated, dont wanna face things. Just wanna go back to bed.

Has your current health or life style altered your normal sleep habits?Pt states: Stress at work makes it difficult to go to sleep.

Do you feel your sleep habits have contributed to any health problems you may have?Pt states: Stress and lack of sleep increases her migraine.

SENSORY-PERCEPTUAL PATTERN 2 Possible Points_______Perception of Senses and pain assessmentDo you have problems with the following: YES NO If yes, describe.

Vision or hearing?Pt states:I am nearsighted & farsighted, and I use glasses.

Ability to feel, taste or smell?(touch, pain, heat, cold, salty, sweet, bitter, sour, odor)

What, if any devices or methods do you use to help you with any of the above problems? (ex.: glasses, contacts, hearing aids)Glasses

Do you have any pain now?Pt states: No pain.

If so, what brings it on? Relieves it? When does it occur? How often? How long does it last?Pt states: No pain.

Rate your pain on a scale of 1-10, 10 being the most severe pain.Pt states: No pain.

Has your pain affected your activities of daily living? If so, how?Pt states: No pain.

COGNITIVE PATTERN 2 Possible Points_______Ability to Understand, communicate, remember, and decision-making YES NO Describe.

Are you able to understand and learn new information easily?

What is the best way for you to learn something new (read, watch television, demonstrate, explanations by someone else, etc)?Pt states: Read the material and start doing it hands on

Do you ever have difficulty expressing yourself or explaining things to others?

Are you able to remember recent events and events of long ago?Pt states: I remember important childhood events.

Do you find decision making difficult, fairly easy, or variable?Pt states: Making decision is fairly easy. I can analyze information quickly.

What assists you in making decisions?Pt states: Information given and the time it was given.

Do you have any history of seizure, stroke, fainting or blackouts?

ROLE RELATIONSHIP PATTERN

Perception of Major Roles and Responsibilities in Family 4 Possible Points_______

Who do you live with? Husband and Son

Are you happy in your neighborhood and the community in which you live?Pt states: Yes, it is a quite neighborhood. The community is friendly and I know a lot of people in my community.

Do you participate in any social groups, community or neighborhood activities?Pt states: I work with the local police department on the effects of stealing and peer pressure sponsored by by work.

What do you see as your contribution to your community and/or society?Pt states: Helping local youth to make the right choices.

Who is the main financial supporter of your family?Husband

If you work how do you feel about the people you work with?Pt states: Directory report are support. Co-worker good to work with. Immediate supervisor overbearing and challenging.

If you could, what would you change about your work?Pt states: Less stress, and less hours.

Are there any major problems you have at work?Pt states: Yes, the number of hours worked.

How does your family get along?Pt states: Family are very close.

Who makes the major decisions in your family?Pt states: I make the decision with my husband.

How do you feel about your family?Pt states: Irreplaceable, my family is my life.

What is your role in your family?Pt states: I am the support system.

Is this an important role?

What is your major responsibility in your family?Pt states: I am the caregiver, and counselor.

How do you feel about this responsibility?Pt states: Good.

How does your family deal with problems?Pt states: We all deal with the problem together. We help each other.

Who is the person you feel closest to in your family?Pt states: My husband.

Who is the most important person in your life and why? Pt states: husband, because he is my partner and everything I do, I do with him.

YESNODescribe:

Are there any major problems now?

Have you ever been emotionally, sexually or physically abused by your partner, someone close to you and/or anyone else?

If yes, would you like a domestic violence hotline phone number?If the person says yes, you may give: The National Domestic Violence Hotline at 1-800-799-SAFE (7233) or 1-800-787-3224 (TTY)

If yes, would you like to talk about this situation?

If yes, describe what it is/was like for you? Have you and/or this person had any counseling?

Family Health History (do not include client) 2 Possible Points_______

Specify any blood relatives (grandparents, parents, siblings, children, aunts and uncles) that have any of the following illnesses DiseaseYESNOIf Yes describe which relation and type of illness

Alcoholism or drug abuse

Allergies

Anemia

Arthritis

Asthma

Breast Cancer

Cancer or tumor (type)

Cardiovascular disease

Colon or bowel disease (including polyps)

Congenital Birth defects

Depression

Diabetes

Drug abuse

Emotional problems (depression, etc)

Emphysema

Glaucoma

Heart attack (before age 55)

Heart murmur

High blood cholesterol

Hypertension (High blood pressure)

Kidney disease

Liver disease

Mental Illness

Migraines

Obesity

Osteoporosis (brittle bones)

Seizures/ Epilepsy

Sickle cell anemia or trait

Skin cancer

Stroke

Tuberculosis

Thyroid disease

Seizure disorder

Other

Draw a Genogram of your clients family (includes client) refer to texts for genogram sample and key): 4 Possible Points_______SEXUALITY-REPRODUCTION PATTERN 3 Possible Points_______

(NOTE: use appropriate questions based on age, gender and past medical history)Female:YESNO YESNO

Age at menarche:Date of last menstrual period:

Are your periods regular?Duration of periods from start to end: _____ days

Do you experience PMS?Last pap smear date and result:

Do you have painful menstruation?Do you have excessive menstrual bleeding?

Do you have vaginal discharge?Do you have spotting between periods?

Do you have vaginal dryness?Have you had repeated yeast infections?

Have you had a history of infertility?Do you have pain during intercourse?

Do you do breast self-exams? (how often?)Date of last GYN exam:

Describe any yes answers:

Pregnancy History: Gravida___________ # full Term______ #Preterm______ # Abortions/Miscarriages _____ # children living_____(total # of pregnancies) (# carried to term)MID-LIFE WOMENDescribe:

If you have had a mammogram, what were the results?

Have you had any peri-menopausal symptoms? (hot flashes, mood changes, sleep problems, menstrual irregularity)

If you have gone through menopause, at what age did your periods stop?

If you have gone through menopause, have you had any post-menopausal bleeding?

Male:YESNOYESNO

Circumcised? If yes, at what age?

Do you do testicular self-exams?Have you had prostate problems?

Have you had penile lesions?Have you had discharge or odor?

Have you had problems with infertility?

Describe any yes answers:

Male or Female:YESNO Describe:

Are you involved in a sexual relationship?

If yes, what do you or your partner do to prevent pregnancy?

Do you have any health issues affecting your sexual relationship?

Do you have or have you ever had a sexually transmitted infection? (gonorrhea, herpes, chlamydia, warts [HPV], HIV/AIDS, trichomonas, syphilis)

Do you use any methods to prevent contracting a sexually transmitted disease?

Do you have any concerns about your sexuality, sexual relationship, and/or sexual performance?

SELF-PERCEPTION-SELF-CONCEPT PATTERN 2 Possible Points_______Perception of Identity, abilities/ self-worth, and body image.Describe yourself:

Do you have any current health problems that are affecting your feelings about yourself? If yes, describe:

What do you consider to be your strengths/ weaknesses?

How do you feel about your appearance?

Would you change your appearance if you could?If yes, describe:

COPING-STRESS TOLERANCE PATTERN 2 Possible Points_______

Perception of Stress and Problems in Life and coping methods and support systemsYESNO Describe:

Do you have any stressful situations in your life now?

Has there been a personal loss or major change in your life over the last year?

Do you use medication, drugs or alcohol to help relieve stress?

Do you have a history of anxiety, mood changes, depression, or other mental health issues?

How do you usually deal with problems?

What helps you to relieve stress and tension?

To whom do you usually turn when you have a problem?

VALUE-BELIEF PATTERN 2 Possible Points_______

Values, Goals, and Philosophical BeliefsWhat do you value most in your life?

What are you most proud of so far in your life?

What do you hope to accomplish in the future?

What is your major source of hope and strength in life?

Religious and Spiritual BeliefsYESNO Describe:

Do you have a religious affiliation?

Is a relationship with God an important part of your life?

Do you have another source of strength that is important to you?

Are there certain religious or spiritual practices that are important to you? (ex. prayer, reading scripture, communion, etc.)

Are there certain religious/ spiritual practices or restrictions that are important for you to follow when you are ill?

Is there anything else you'd like to mention that we haven't covered?

MEDICAL CONDITIONS 2 Possible Point_______

Have YOU ever been diagnosed with any of the following? (Please check even if already listed previously)YESNOIf current problem, note date diagnosed and type of conditionIf problem resolved, note date resolved

Alcohol problem

Allergies (type)

Anemia

Anorexia/Bulimia

Arthritis

Asthma

Cancer or tumor

Colon or bowel disease (include polyps)

Coughs (that last for more than 2 weeks)

Depression

Diabetes

Emotional Problems

Emphysema

Fainting

Gallbladder trouble

Glaucoma

Gout

Headaches

Heart trouble

Heart murmur

High blood cholesterol

Hypertension (high blood pressure

Kidney problems (or stones)

Liver disease (cirrhosis, hepatitis)

Mental illness

Migraines

Obesity

Osteoporosis

Radiation treatment (where & when)

Seizures/Epilepsy

Sexually transmitted disease

Sickle cell anemia or trait

skin rashes or lesions

stomach or duodenal ulcer/pain

stroke

TB

Thyroid condition

Urinary track infections

Other

Check here if none of the above

OPQRSTU ALL PROBLEMS NOTED: (15 possible points) _______________________

Problem:

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List Client Strengths and Areas of Improvement 9 possible points _____________

Client StrengthsClient Areas of Improvement

Client keep up with annual exam such as

physical, dental and gynecological exam.

Client is health conscious and does not drink or smoke.

Clients diet consist of low carbohydrates

Client needs to manage the stress at her work

3 Nursing Diagnosis List By Highest Priority 15 Possible Points _______Nursing Diagnosis Data to support Nursing DiagnosisRationale for Priority

1.Highest Priority

2.Second Priority

3.Third Priority

2 References Write in APA format 2 possible points 2 Possible Points ___________

1.2.

Guidelines for Health Assessment of a Middle Age Adult Score Sheet Submit no later than Tuesday, October 10th, 2012 at the beginning of lab. For every day (including weekend days) the assignment is late 5 points will be deducted from the total score.

This Score Sheet MUST BE ATTACHED to the Health History you hand into your lab instructor.Name of student: _________________________ Lab Instructor: ______________________

Evaluation Possible Points Earned Points Comments

Health History (see actual form to see how points are divided up on each section)

55

Put a star next to areas that suggest possible/actual problems, and Fully describe (Use OPQRSTU as guideline) all abnormal findings

15

List all client's strengths and areas for improvement

9

Formulate and prioritize 3 nursing diagnoses (NANDA). List the clues data in the Health History that support each Nursing Diagnosis. Give your rationale for prioritizing.

15

List 2 references may use Carpenito, Jarvis and/or Weber as guides for making Nursing Diagnosis and prioritizing. Jarvis Chapter 1 is a good reference for critical thinking.

2

Use professional terminologies, correct spelling, and write neatly in ink or typed. Must use original form.

Must submit paper copy.

3

Score sheet attached to Health History when handed in to lab instructor. 1

Total:

100

Hc2003, kg 2012