Running Head: HEALTH ASSESSMENT
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Health Assessment
Tammy Fisher
N495
Module 8
Aspen University
Sandra Chen-Walta, D.N.P., B.S., M.S.
February 2014
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Comprehensive Health Assessments of Three Patients
Assessment is the collection of information about an individual patient’s health state (Jarvis,
2012). Both subjective and objective data collected will comprise the comprehensive assessment
information. Assessment information will assist in making a clinical judgment or diagnosis
about the health state of the individual. The purpose of this paper is to complete three
comprehensive assessments: child under the age of ten years, a pregnant woman, and an adult
over the age of 65.
Comprehensive Health Assessment of a Child
Dominick is a two month old, caucasian light skinned male. Health history and information
was obtained from his mother, Katie. His birth weight was 8 pounds, 9 ounces, and 21 inches in
length. His apgars were 9-9. He had a head circumference unknown per his mother. He had no
difficulty after birth, was kept in his mother’s room and they both discharged to home the day
following birth. Dominick has been breast fed since birth. He has no family history of disease
except that his mother has asthma that is treated with inhalers and steroids if required. His
mother had no preeclamsia and no gestational diabetes. She took no medications and had no
asthma flare ups so did not have any hospital stays while pregnant. His mother does not smoke
or drink alcohol. Labor was uneventful, lasting 22 hours total, with epidural for pain control. He
was born at 40 weeks, 1 day gestational age, after one sonogram for fetal growth assessment.
Post-natal status: No colic, no constipation, has had no illnesses and no hospital stays. Has
had follow up with the doctor. He has no known allergies and takes no medications.
Dominick has had two appointments with his doctor and has had his first two Hepatitis B
vaccines, and will be getting his first vaccine series next week at his doctor appointment.
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Objective Information: Dominick currently weighs 12 pounds, 6 ounces (50th percentile), and
is 23 inches long (25-50th percentile), while his head circumference is 35 centimeters (above the
95th percentile), and his chest circumference is 36.5 centimeters (The Baby Center, 2014).
Respirations of 38, pulse of 110, and temperature was 97.8 axillary. He is smiling and happy,
tracking movements with his eyes. His mother reports that he rarely cries, sleeps about 4-6 hours
at a time, and breast feeds at least 6 times per day. He has no noted cradle cap and has a slight
amount of thin, dark hair with some thinning noted above ear areas on each side. Skin is soft and
pink with no noted diaper rash or rash otherwise. He has a noted 3cmx2cm café au lait spot on
his right upper buttocks.
HEENT: Head circumference noted above, head is symmetric, eyes track equally with pupils
equal and reactive to light, blink reflex is present, optic disc noted pink bilaterally with noted red
reflexes. No exudate noted from either eye. Ears are clear and patent, placed in normal
alignment, and Dominick startles with loud sounds. Tympanic membranes are gray and shiny.
Nose is patent and without drainage, inner canals are not red. Mouth is patent without lesions
noted, and no thrush noted. Cranial area is soft, noted suture lines are filling.
Chest and Heart and Lungs: Respirations of 38 and pulse of 110 noted. Chest circumference
36.5 cm, nipples aligned. Lung sounds are clear and equal in all lobes. Mother of child reports
that there has been no wheezing, no increased respiratory effort and there are no smokers in the
household. Thoracic cage is rounded. Spine appears straight and vertical. No noted murmurs.
Skin remains pink when crying, no noted circum-oral cyanosis. Fontanelle is soft and flat with
no noted filling.
Abdomen: Bowel sounds are active in all four quadrants, mother reports soft yellow-brown
stool this morning. Stools average two to four times daily per mother.
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Musculoskeletal and Neurological: Leg lengths appear to be comparable, hips are in correct
alignment without dislocation and there appears to be no twisting of the tibias. Gluteal folds are
noted as equal. No dimple at spine noted, no foot inversion noted. Per mother, there is no
history of seizure activity. Rooting and sucking reflexes are noted. When lying on his back is
able to flex and extend legs. Head control noted as well as plantar and palmar grasp. Babinski
reflex is in place to both feet. Moro and tonic neck reflexes are positive. Placing reflex is also
positive.
Male Genitalia: No noted redness or rash to penis or scrotal areas. Per mother, infant
urinates at least six times daily, many times more frequently. Penis size is small and infant is
circumsized. Testes are descended and equal size.
Proposed schedule for Immunizations would be:

Birth –Hepatitis B

One Month-Hepatitis B

Two Months- Diptheria, Tetanus and Pertussis (DtaP), Haemophilus Influenza B (Hib),
Polio,
Pneumococcal, Rotovirius

Four Months- DtaP, Hib, Polio, Pneumococcal, Rotovirus

Six Months- DtaP, Hib, Pnuemococcal, Rotovirus

Six to Eighteen Months- Hepatitis B, Polio

Twelve to Fifteen Months- Hib, Measles/Mumps/Rubella (MMR), Pnuemococcal,
Varicella

Twelve to Twenty Three Months- Hepatitis A

Fifteen to Eighteen Months- DtaP

Four to Six Years- Varicella, DtaP, Polio, MMR
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Eleven to Twelve Years- DtaP booster, Meningococcal, Human Papillomavirus

Yearly- Influenza vaccines beginning at six months, with initial dose requiring a booster
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(The Baby Center, 2014)
Dominick’s mother, Katie, states that she has no issues or questions about Dominick’s care,
even though he is her first child. She has much support from her mother who lives nearby. She
is happy that Dominick has no medical problems noted at this point and is planning his next visit
to the doctor for his vaccinations. She states she has a pamphlet from her doctor that gives her
the list of vaccines and also the probable visits to the physician that are needed in the future
schedule of his care. Katie has her family to provide care for Dominick during the day so she
does not place him in child care.
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References
Jarvis, C. (2012). Physical examination and health assessment (6th ed.). St. Louis, MO:
Saunders.
The baby center. (2014). Retrieved from http://www.babycenter.com/vaccines
The baby center. (2014). Retrieved from http://www.babycenter.com/baby-child-growthpercentile-calculator
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Comprehensive Assessment of a Pregnant Woman
Jennifer is a 28 year old light skinned, caucasion female who is currently expecting her first
child in September of 2014. She has had one spontaneous miscarriage two years ago at
approximately six weeks gestation. Her last menstrual cycle began on 11/26/2013, and her
estimated date of delivery is 9/2/14, which places her baby at the gestational age of 8 weeks/4
days (Baby2see trimester calculator, 2014). Jennifer states that she is 5’10” and weight prior to
pregnancy was 153 pounds, which places her in the normal weight range with a BMI of 22 which
is healthy (Centers for Disease Control and Prevention, 2013). Jennifer denies any surgeries
other than the Dilation and Curettage that she had after losing her first child. She has regular pap
tests at her doctor office yearly and breast exams yearly, as well as self-exams. She has no other
gynecologic or obstetric history and her labs that were recently drawn at the pregnancy check-up
are pending. She and her husband have planned this pregnancy, after giving time to recover
from the loss of the first fetus. She denies bleeding, cramping, headaches, and nausea. She
states she feels great and has begun her prenatal vitamins daily. Jennifer denies vaginal itching
and burning. She has no cats, just two dogs. She has no allergies and plans to breastfeed. Her
family history includes: her parents are both living as is her brother, her mother has atrial
fibrillation and has had multiple kidney stones, and her father has no diseases. Jennifer’s
paternal grandparents are living, her paternal grandmother and paternal aunt died of breast
cancer, and there is diabetes on her paternal side of the family, even though her father is not
diabetic. Jennifer’s maternal grandparents are living and both have atrial fibrillation and
hypertension. Jennifer reports that she had chickenpox when she was about six years old, and
had all vaccines as a child. She has had no injuries and does not smoke or drink. She walks at
her workplace building each day and she has been eating balanced meals and taking her prenatal
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vitamins with her regular diet, as she is not on any specialized diet. Jennifer goes to the dentist
every six months, was recently there on November 1, 2013, she wears glasses and has no other
diseases. She gets a yearly flu shot through her workplace every October.
Objective assessment includes: Temperature of 98.3-pulse 80-respirations 12-blood pressure
of 122/68, and her pulse oximeter on room air is 99%. She is groomed and clean with shiny
blond hair, and appears well-nourished. Mucous membranes are pink and moist. Head and face
are symmetrical with nose patent and nares non-reddened. Eyes are clear and without exudate
with positive red reflex and positive lens clarity with the optic disc pink, smooth and circular.
She is able to read the eye chart correctly with her glasses in place for correction of mild myopia
(Jarvis, 2012). Her ears have shiny grey eardrums with no drainage noted and she can hear a
whispered voice without difficulty. The throat is without redness, she states she had no
tonsillectomy and she has no difficulty with swallowing. Her breasts are equal in size with no
noted drainage from nipples, and breasts are not enlarged. There is no noted murmur and her
heart and lung sounds are clear and no noted abnormalities. Jennifer denies nausea, had her most
recent bowel movement today, and her bowel sounds are equal in all four quadrants. Her legs
are not swelled and she denies calf tenderness, and has negative Homan’s signs. There is no
fundus measurement yet as she is only at the eight week gestation mark. Jennifer denies frequent
urination and states she drinks about 40 ounces of fluids per day.
The planned care for Jennifer during her pregnancy would include:

Begin prenatal vitamins

Urine testing and prenatal lab screenings

Human Immunodeficiency Virus (HIV) testing offered

Providing information on nausea control as needed
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Information on warning signs of preterm labor

Set up return visits, usually monthly for the first 6 months, then increasing in frequency
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to weekly during the final month of pregnancy. The physician may desire more visits
with high risk pregnancy members, especially if there are complications.
(Jarvis, 2012).
Jennifer may need to be enrolled in the Women Infants and Children (WIC) program for
nutritional support during her pregnancy if she has financial need. She also will require further
lab testing for anemia, hyperglycemia, Rh factor and other pregnancy indicators. Each physician
visit will include a urine dipstick test for proteins to detect preeclampsia. Educational materials
on the pregnancy, the growth of the fetus, and the continued physician visits should be provided
to Jennifer at the physician office.
Jennifer is a healthy 28 year-old with a history of spontaneous miscarriage about two years
ago. Jennifer and her husband has been patient in waiting and planning for the physical and
mental healing for Jennifer after she lost her first child at about four weeks gestation. She is
aware of the planned visits for her obstetrician and she already has chosen a pediatrician for the
baby. Jennifer has stable health at this time, and is planning to breast feed. She is not in need of
the WIC program support. Jennifer and her husband are looking forward to her obstetrical visits
and the birth of their baby. Jennifer has been given information on the growth and development
of the fetus and also the planning program for her physician visits and lab testing in the next few
months and she verbalized understanding of the plan.
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References
Baby2see trimester calculator. (2014). Retrieved from
http://www.baby2see.com/trimester_calculator.html
Centers for Disease Control and Prevention. (2013). Healthy weight. Retrieved from
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi
_calculator.html
Jarvis, C. (2012). Physical Examination and Health Assessment (6th ed.). Saunders: St. Louis.
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Assessment of Adult over the Age of Sixty-Five
Jim is a 74 year old Caucasian male who has consented to comprehensive health assessment.
He is 68 inches tall and weighs 178 pounds which is overweight with a BMI of 27.1 and a
maximum healthy weight desired to be 164 pounds (Centers for Disease Control, 2013). Jim’s
vital signs are: Temperature orally of 98.0, pulse apically of 88, respirations of 14 and blood
pressure of 138/82. Jim’s parents are deceased and he has no children. He lives with his wife of
the same age. Jim still drives a car and volunteers weekly at the area soup kitchen. Jim states he
had all of the usual diseases when a child: chicken pox, measles, mumps and the usual viruses.
He has had no lasting effects. Jim wears glasses for myopia, and is able to read newspaper and
drive a car without difficulty. His head is symmetrical and he tracks with his eyes. He is able to
read the eye chart correctly with his glasses on and says he went to the eye doctor just a month
ago and no change in his glasses and no glaucoma noted by his doctor. Jim states that he had a
broken right femur when he fell out of a tree at age of 8 years, other than that no injuries. He has
hypertension and takes one Metoprolol per day. Jim also states that the doctor told him to wear
support hose as he has a history of cold feet and the doctor told him it would help him. Jim
controls the intake of salt by not using the salt shaker and he also does not eat canned soups or
bacon and if something is salty tasting he does not eat it. He has a blood pressure machine at
home and takes his blood pressure daily and is to report a blood pressure of over 150 systolic or
over 100 diastolic to his doctor. He states that since starting the Metoprolol five years ago his
blood pressure has never been high enough that he had to call the doctor. Jim is unaware of
health problems that his parents or grandparents had and states they lived to over the age of 80.
Jim denies any illnesses of chest or lungs, no gastric issues, no hospital stays, and no fractures
other than when he had the femur fracture at age of 8 years. He does smoke two to four
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cigarettes daily and voices understanding of the risks of smoking, but he has smoked for over 50
years so he says that he is not interested in quitting. He denies heart problems or surgeries, and
denies bowel issues. He states that he has to get up one time to urinate each night but the doctor
has tested for prostate issues and says he has none, just to drink less before he goes to bed. Jim
states he has never used a cane or a walker.
Objective information: Jim has a tongue that is midline when he sticks it out, he can smile,
blink and touch his nose with his finger. Jim has had a history of nasal environmental allergies
but is on no medications. His nares are patent, with slight pink tinge. He has grey eardrums that
are shiny and he denies hearing deficits and hears the whispered words behind him. His trachea
is midline, he has no swallowing deficits, and his lymph nodes are not swelled. He has no noted
tics or tremors and he wears dentures, both upper and lower. His red reflex is positive in each
eye, the optic discs are each pink and somewhat hard to note. His iris is pale brown, somewhat
dull, and his pupils are somewhat slow to react to light. He wears glasses for presbyopia and
with the glasses can read the eye chart correctly. Jim’s ears are normally positioned with no
redness noted to ear canals and he has a grey and shiny eardrum in each ear. He is able to hear
the whispered word and has never worn hearing aids. Jim’s lungs are clear and he voices
understanding of the risks of smoking but is not willing to stop. He has no shortness of breath
and no use of oxygen. There are no noted murmurs or abnormal heart sounds, although the pulse
is 88 apical. Homan’s signs are negative bilaterally, pulses in the feet are palpable and strong,
while pulses radially are palpable and strong. Jim’s most recent bowel movement was this
morning and his bowel sounds are active in all four quadrants. Positive tympany noted on all
four quadrants and no noted tenderness. No crepitus noted in hips, knees or temporomandibular
joint. Jim states he has some arthritic type pain and that he is moving slowly but that he uses no
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appliances to walk. He is able to flex and extend his arms and knees and abduction of his hips is
slow but moveable. He has no fluid noted at knees or joints. Feet are symmetrical with corns
noted on the balls of feet. Jim states he soaks his feet about every other day in Epsom Salts per
the doctor’s information. Jim’s spine is straight and he denies any spinal issues except for
feeling old and moving slowly.
Jim is a 74 year old male who is able to ambulate independently and care for himself. He has
hypertension and takes one medication for its control. He also wears support hose as he has poor
circulation in his feet per the doctor. Jim has had one fracture when he was eight years old. He
is on a regular diet with self-imposed salt control. He will need to get a yearly influenza vaccine
and also a pneumonia vaccine every 10 years, varicella vaccine and tetanus on an as-needed
basis per patient needs (Centers for Disease Control, 2013). He will require yearly follow up at
the doctor office and the dentist office. Jim verbalizes understanding of hypertension and the use
of his medication, along with a salt controlled diet. He is overweight and states that he is cutting
out the sweets and the high fat foods and is willing to give that time to see if that assists him in
losing weight to reach his ideal weight of 164 pounds. When giving Jim the Lawton
Instrumental Activities of Daily Living Scale, he receives an eight or a perfect score (Jarvis,
2012).
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References
Centers for Disease Control and Prevention. (2013). Healthy weight. Retrieved from
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi
_calculator.html
Centers for Disease Control. (2013). Recommended immunization schedules for adults. Retrieved
from http://www.cdc.gov/mmwr/preview/mmwrhtml/su6201a3.htm
Jarvis, C. (2012). Physical examination and health assessment (6th ed.). St. Louis, MO:
Saunders.