NURS 3200
Health Assessment Documentation Template
HEALTH HISTORY
Biographical data:
Name: J.P.
Address: 400 E. Somewhere Road, #123 St. George, UT 12345
Phone number: (435)123-4567
Contact person (relationship to patient): J.P. (Mother)
Age: 20
Birthdate: 6/24/1993
Marital status: Single
Number of dependents: 0
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Birthplace: St. George, Utah
Gender: Female
Educational level: College Graduate
Occupation: RN
Ethnicity/nationality: White/Caucasian Advance directive: None
Social security number: 123-45-6789 Health insurance: Altius
Referral: Dixie State University Project
Source of history/reliability: Self
Reason for seeking healthcare: Check-up/Physical (Primary Healthcare)
Current health status: Good/no current issues
Past health history:
Childhood illnesses: Chickenpox. Pt denies other usual childhood illnesses, including Measles, Mumps, and Rubella.
Hospitalizations and surgeries: Umbilical hernia repair, gum grafts, and removal of wisdom teeth
Serious injuries: None
Serious/chronic illnesses: None
Immunizations: Current
Allergies: Ceclor
Medications: None
Travel: U.S. only
Military service: N/A
Family history:
Spouse: N/A
Children: N/A
Mother: Anemia
Father: Ulcerative colitis, cervical spine fusion
Grandparents: Skin cancer, lymphoma, dementia, Alzheimer’s disease
Siblings: None
Aunts: Brain tumor (benign)
Uncles: Stroke, heart disease
Cousins: None
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(Alternatively, family history can be documented using a genogram. See example below and on page 53 of your textbook. Do not include a narrative health history and genogram. One or the other will suffice.)
Review of systems:
General health survey: Pt reports feeling generally well with no complaints.
Skin, hair, and nails: Denies rash, dryness, irritation, and presence of lesions
Head and neck: Denies headaches, head injury, and vertigo. Pt reports dizziness upon standing quickly.
Nose and sinuses: Pt denies discharge, nosebleeds, unusually frequent or severe colds, nasal obstruction, sinus pain, hay fever, and decreased sensitivity to scents.
Mouth and throat: Pt denies mouth pain, frequent sore throats, lesions in mouth or tongue, tonsillectomy, hoarseness, dysphagia, altered taste, and bleeding gums. Pt reports that wisdom teeth have been removed.
Eyes: Pt reports wearing contacts. Pt denies blurring and blind spots when contacts in place. Pt denies eye pain, diplopia, redness, swelling, discharge, and glaucoma.
Ears: Pt denies ear infection, earache, discharge from ear, tinnitus, and vertigo.
Respiratory: Pt denies history of lung disease, including COPD, pneumonia, asthma, bronchitis, pneumonia, and tuberculosis. Pt denies dyspnea, shortness of breath, cough, hemoptysis, exposure to toxins/pollutants, and wheezing.
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Cardiovascular: Pt denies chest pain, retrosternal pain, palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, and anemia.
Breasts: Pt denies breast pain, lumps, nipple discharge, rash, history of breast disease, and breast surgery.
Gastrointestinal: Pt denies changes in appetite, heartburn, intolerance to foods, pain with eating, pyrosis, nausea, vomiting, vomiting blood, history of ulcers, appendicitis, black stools, and rectal bleeding. Pt reports occasional constipation and occasional use of stool softeners.
Genitourinary: Pt denies frequency, urgency, nocturia, dysuria, polyuria, hesitancy, narrowed stream, and incontinence. Pt reports urine is yellow and has no foul odor. Pt denies kidney stones and flank pain.
Reproductive: Pt denies amenorrhea and dysmenorrhea. Pt reports 28 day cycle between menstrual periods.
Neurological: Pt denies history of seizure disorder, stroke, fainting, blackouts, weakness, tics, tremors, paralysis, numbness, tingling, and coordination problems. Pt denies memory disorder, mood disorder, depression, and anxiety.
Musculoskeletal: Pt denies joint pain, swelling, cramps, abnormal muscle pain, deformities, limited motion, arthritis, gout, and gait problems.
Immune/Hematologic: Pt denies bleeding tendency, excessive bruising, lymph node swelling, blood transfusion reactions, and exposure to toxic chemicals and radiation.
Endocrine: Pt denies history of diabetes, polyuria, polydipsia, polyphagia, thyroid disease, intolerance to heat and cold, excessive sweating, changes in hair distribution, and hormone therapy.
Developmental considerations:
Patient’s developmental level is young adulthood. Pt reports healthy relationship with fiancé, as well as family and friends, which fulfill the need for loving relationships with others. Patient is successful regarding educational and work-life achievement, with positive outlook on life. No current or previous developmental defects or delay noted. Patient is appropriate for age and developmental level.
Psychosocial profile:
Health practices and beliefs: Biomedical health paradigm
Typical day: School, work, socialization, exercise
Nutritional patterns: Follows food pyramid guidelines
Activity and exercise patterns: Exercises 5x/week for about 1 hour per session
Recreation, pets, hobbies: Pt states she enjoys hiking, running, reading, TV.
Sleep/rest patterns: Pt sleeps 7 hrs/night and denies insomnia.
Personal habits: Pt denies drug, alcohol, and tobacco use.
Occupational health patterns: Pt states she uses exercise to assist in stress management. Pt reports resting before work, staying hydrated, and taking time to eat during her break at work.
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Socioeconomic status: Pt states she is above the poverty line and holds a job.
Environmental health patterns: Low pollution in current environment, no exposure to second-hand smoke.
Roles, relationships, self-concept: Pt reports appropriate level of self-esteem.
Cultural influences: Pt reports influence of German heritage.
Religious/spiritual influences: Pt states she is a member of the LDS church.
Family roles and relationships: Pt fulfills family roles of daughter and sister.
Pt states her relationships between friends and family are healthy.
Sexuality patterns: Heterosexual. Practices abstinence.
Social supports: Pt reports positive support systems of friends and family who live locally and are available for support.
Stress and coping patterns: Pt reports using exercise and relaxation to cope with stress.
PHYSICAL ASSESSMENT
General appearance:
J.P. is a pleasant young lady in her early twenties. Physical appearance is appropriate to age. Grooming and hygiene are appropriate, with no foul odors.
Nutritional status is appropriate with appropriate weight for height and no emaciation or obesity. J.P. is alert and oriented with no decrease in LOC.
Verbalization is appropriate to age and situation. Affect is pleasant with no sign of depression or anxiety. Gait is smooth and posture is upright and appropriate.
Movements with ambulation are smooth. J.P. demonstrates no gross deformities or signs of distress.
Vital signs:
Temperature: 98.4
Pulse: 64
Respirations: 16
Blood pressure: 110/76
Height: 5’3” Weight: 125 lbs BMI: 22
Systems:
Integumentary:
 Skin is warm dry and intact. Skin color is tan to pink with even pigmentation.
No suspicious nevi are present. Skin turgor is good and skin texture is smooth.
(Remember that you are required to choose only 5 of the following to examine. Delete
the two that you do not examine when you document.)
Head, Face, and Neck:
 Head: o Head is appropriately sized with normal round shape. Features are symmetrical. Hair is distribute thickly on scalp, with no facial hair. No gross lesions are present.
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Page 5 o Scalp is appropriately mobile, without tenderness. Hair texture is smooth. o TMJ movement is smooth with no grinding of jaw. Temporal artery pulses palpable bilaterally, 2+.
 Face: o Nasolabial folds slightly off-centered; present since birth per pt report. o All facial movement symmetrical (puff cheeks, raise eyebrows, close eyes, wrinkle forehead). CN VII intact. o Facial sensory function intact (Cranial Nerve (CN) V intact). o Facial skin warm dry and intact without acne or lesions.
 Neck: o Thyroid without nodules, masses, tenderness, or enlargement. o Lymph nodes non-tender and without enlargement or swelling. o Trachea midline. o Full ROM of neck intact. o Cranial nerve XI intact. Neck strength symmetrical with 5/5 strength.
Nose, Mouth, and Throat:
 Nose and Sinuses: o Sinuses non-tender without swelling. Nasal passages patent bilaterally. o CN I intact. Pt sense of smell intact. o Nasal mucosa moist and pink in color. Septum slightly deviated to left; this finding is congenital per pt report. Septum, nasal mucosa, and
 Mouth: turbinates are otherwise normal. o Oral mucosa and lips without lesions, oral mucosa moist and pink in color. Tongue pink without spots or evidence of thrush. Good dentition with no missing teeth with exception of wisdom teeth. Gum grafts pink with no evidence of tissue rejection or tissue damage. o Tonsils visible but not enlarged. Posterior pharynx without erythema or exudates. o Sense of taste, tongue mobility, and gag reflex intact.
Eyes and Ears:
 Eyes: o Visual acuity 20/20 when contacts in place. CN II intact. o Visual field intact by confrontation. o EOMs in 6 cardinal fields of vision intact. o Corneal light reflex intact. o Cover test negative with no phoria or tropia. o Conjunctive clear, sclera white, iris intact and lids normal without ptosis. o Pupils equal, round, and reactive to light and accommodation. o No abnormal discharge from lacrimal ducts, glands non-tender.
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Page 6 o Fundi: Light red to brown in color with no lesions, hemorrhages, exudates, or microaneurysms.
 Ears: o External ear without lesions, tenderness, discharge, or gross deformities. o Angle of attachment normal. o Whisper test reveals no impairment in hearing. o Tympanic membranes intact, eardrum translucent. No air bubbles or effusions visible.
Lungs:
 Inspection o Normal respiratory effort with no accessory muscle use.
Anterioposterior-lateral ratio is 0.7, with cylindrically oval chest shape. The costal angle is approximately 75 degrees. There are no visible spinal deformities.
 Palpation o Chest expansion is symmetric. No mass, tenderness, or crepitus present. No tactile fremitus.
 Percussion o Resonance to percussion present and symmetrical, all lung fields.
Diaphragmatic excursion 5.5cm.
 Auscultation o Lungs sounds clear to auscultation, all lung fields, without crackles or wheezes.
Cardiovascular:
 Inspection o NO JVD. Neither carotid or jugular pulsations visible. Apical impulse not visible.
 Palpation o Carotid arteries palpable with 2+pulsations. Apical impulse palpable; no thrill present. Bilateral radial, ulnar, posterior tibialis, and pedal pulses palpable, 3+.
 Auscultation o S1 and S2, regular rate and rhythm, no murmur, no gallop, no rub, no carotid bruits.
Summary of Pertinent Findings from Health History and Physical Assessment:
Patient is in good health with no complaints. Physical assessment shows no focal defects, deformities, or significant abnormalities. Review of symptoms reveals healthy habits and high patient regard for personal health.
Actual and Potential Health Problems:
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No current symptoms or risk factors currently present. However, due to familial risk factors related to family history (anemia, ulcerative colitis, lymphoma, dementia,
Alzheimer’s disease, brain tumor, stroke, and heart disease) these are all potential problems.
Nursing Plan of Care:
Patient will be advised to continue with current diet and exercise regimen.
Additionally, patient will be advised to continue to follow age-appropriate recommendations for physical exams, health screenings, and check-ups. Continue to manage risk factors for CAD with appropriate diet and exercise. Listed below are recommendations for patient based on potential problems related to family history:
Anemia: If symptoms of anemia, such as fatigue, present, draw CBC. Advise patient to follow diet high in iron-rich foods, folate, and B12.
Ulcerative colitis: Advise patient to report changes in bowel habits and abdominal discomfort. If symptoms present, colonoscopy may be indicated.
Lymphoma: Monitor for swollen lymph nodes. May monitor WBC and CBC with diff due to patient risk for lymphoma.
Dementia and Alzheimer’s disease: These conditions are low-risk at this time.
Brain tumor: Monitor for headaches, neurological changes, personality changes. If significant changes occur, CT scan may be indicated.
Stoke: Patient has low risk for stroke due to age and high level of physical fitness.
However, plan to monitor cholesterol levels with blood tests.
Heart disease: Instruct patient to check blood pressure regularly and to follow healthy diet (low fat, low sodium, or Mediterranean diet). Continue to monitor BP, cholesterol, and activity level. Instruct patient to report chest pain, shortness of breath, and palpitations. Keep stress level low.
J.P. is in an overall state of excellent health. The above recommendations are to address potential problems, although the her risk for these conditions are currently low. Continue to monitor J.P. through yearly check-ups, and instruct J.P. to continue with annual health screenings.
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