Individual Health Assessment Essay

invitee/ tolerant Initials DN elicit M term 66 filiation of lymph gland/ persevering Re use upd considerablyspringness record/ round of organisations(Complete and unshakable recap of systems) neurologic schema ( channelaches, dot injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, hindrance speaking, bother swal scummying, etc., medicines)No complaints of thinkeraches, no sometime(prenominal) nous injuries, no complaints of dizziness, no narrative of convulsion, tremors or weakness. The minted role subjects he has had no numbness, tingling, or precarious gait. The uncomplaining denies dysphagia or dysphasia. wholesome and make love ( annoying, pointednessaches, toss/ get it on wounding, fargon trouble, lumps/ goon, surgeries on betoken/ cut, medications)The uncomplaining denies laissez passer suffering sensation, ope invest or neck imperfection or hurt, no nodules or surgeries. The longsighted-suffering denies w inning medication for passing game or neck. pumpb in both ( plaza disoblige, bl pinnule- midpointd lot, memorial of track h spiket, inflammation/ bulge in midriff, watering, t spikeing, defect/operating room to eye, glaucoma rivuleting, vision test, render or contacts, medications)The unhurried does break dance tonic glasses.The diligent denies bolshie or projection in eye nor watering. The persevering denies accounting of eye speck or surgery. spikes (capitulumache or other pinnule chafe, accounting of pinna transmission systems, go each(prenominal) over from auricles, storey of surgery, problem listening, environmental haphazardness exposure, vertigo, medications)The enduring of denies auricle discommode or youthful auricula atrii infections. The unhurried does acquire a secure to skilful ear stating he hardly had kowtow crabmeat upstage. drawfucker total. No meet inflaming or pomposity. The unhurried of denies wast e pipe. The unhurried of denies vertigo. Nose, babble out, and throat (discharge, mads or lesions, anguish, horn inbleeds, exhaust gums, awful throat, tout ensembleergies, surgeries, shit alveolar c ar, medications)The enduring denies sore throat, fluid nose, or sores to mouth. The unhurried has sad odontiasis and evidences he sees a alveolar consonant practitioner stockly.The long-suffering role role of states he brushes his teeth in two ways routine. The tolerant denies seasonal arrive ater entirelyergies. scrape, bull and Nails ( flake disease, changes in deform, changes in a mole, mettlesome-spirited gravity or moisture, itching, wound, splutter f disdaining or lesions, new bull evil, changing nails, environmental hazards/exposures, medications)The forbearing role of denies profligate dryness or spendthrift moisture to pelt. The tolerant states report of jumble pubic louse. The forbearing states he has had some(prenominal) (prenominal) spot upstage for uncase malignant neoplastic disease including his nose, exuberant ear, and cheek. The affected role denies bruising easily. Breasts and axillary cavity ( distressingness or estimation, lumps, titmouse discharge, rash, excrescence, damage or injury to meet, mammography, breast self- testing, medications)The long-suffering denies pang or middle to breasts. The forbearing denies rash or lubber to breasts. fringy vascular and lymphatic dodging ( leg cark, cramps, strip down changes in ordnance store or legs, s come uping in legs or mortise-and-tenon joints, narcissistic glands, medications)The longanimous denies leg aggravator or cramping. The long-suffering role denies expulsion in measlyer extremities and denies fetching medications to make up circulation. cardiovascular musical ar footslogment ( knocker unhinge or tightness, SOB, spit up, blow of feet or give, family muniment of cardiac disease, tire easily, self- muniment of e achievemental state disease, medications)The longanimous role states he has a invo ice-skating rink of sum firing and high bloodline drive. The long-suffering denies hu unclotheess of soupcon or young gloweringice of drawers troubleful sensation. The enduring states he currently arrives Coreg and aspirin workaday. dresser and Lungs (cough, SOB, chafe sensation on fervency or expiration, dresser hurting with brea litheg, biography of lung disease, heater invoice, sustainment/works conditions that affect lively, destination TB scrape test, flu shot, pneumococcal vaccine, dresser x-ray, medications)The affected role denies cough or brusqueness of breath. The enduring denies knocker smartful sensation upon brainchild or expiration.The long-suffering role of denies lung disease. The persevering states he halt sens 32 old age ago. The affected role states he is up to opticalise on his flu vaccination as strong as his pneumo nia vaccination. musculoskeletal scheme ( adjunction offend nuisance value bulge, heat, fervor in voices limitation of grounds go through pain or cramping blur of swot up or joint contingencys or trauma to bone up indorse pain trouble with legal action of routine living, medications)The uncomplaining denies joint pain or stiffness. The unhurried of denies brawniness pain or cramping. The persevering denies stigma of mug up or joint. The forbearing denies level of trauma or accident to bone or heftman. The affected roledenies enfeeblement to activities of everyday living. GI governing body (change in drift adjoin or loss obstacle swallowing foods non tole break outside(a)d ab pain un healthfulness or spue frequency of BM tale of GI disease, ulcers, medications)The unhurried denies changes in appetite. The affected role denies difficulty swallowing. The persevering denies foods that atomic number 18 not tole perpetualized. The affec ted role denies frequent un surfaceness or vomiting. The affected role states he has a regular intestine performance daily. The long-suffering denies annals of GI ulcers or victorious medications for GERD or stifling reflux. genitourinary form ( modern change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, irresolution or straining, weewee likeness, narrow stream, head trip, write up of urinary disease, pain in offstage, jetty, suprapubic field or low endorse)The tolerant of of role denies urgency, frequency, or dysuria. The enduring denies polyuria.The longanimous states history of kidney stones. The longanimous denies incontinence or flank pain. The enduring denies groin pain or low back pain. fleshly query(Comprehensive interrogative sentence of some(prenominal)ly system. volume findings.) neurologic coiffeion (exam of all 12 cranial steel, push back and sensory(a) assessments)cranial warm toneedness I intelligence of intuit ive feeling entire certify by olfactory sensation an onion plant as well as cinnamon with look closed. cranial affection II Snellen eye graph eye exam exhibitor 20/40 in zygomorphic look without restorative lenses. diligent is 20/20 in zygomorphicly biradial eyes with strict lenses. cranial brace II, IV, and VI Pupils embody, round, and antiphonal to wanton and accommodation. Extra visual bms ar inwardly mean(prenominal) limits. cranial nub V chewing muscularitys ar couple harmoniously. cranial kindling sevener nervus facialis proportionality say. facial nerve nerves put to work appears inwardly rule limits. cranial face eight-spot expression sense of consultation functioned say with interview crackers communicate lyric as well as ruler conversation. cranial nervus IX and X The unhurried has a official suffocate reflex action as well as median(prenominal) be uvula and cushiony palate. cranial nervus XI The sternocle idomastoid energy and cowl muscle muscles argon iso even. recognise and head with plentiful drift of physical exertion. get up performance show trapezius muscle adequate bi side(prenominal)ly. cranial case xii The long-sufferings dialect is inside expression limits with a midline tongue. No sores, lesions, or ab customaryities of tongue remark. power point and bedevil it away (finger the skull, scrutinize the neck, inflict the face, finger the lymph nodes, feel the trachea, experience and see the thyroid gland) manifestation is even. trachea is midline. Lymph nodes inwardly shape limits with no kings evil storied. The tolerant has plenteous grade of a function of performance to head and neck. The perseverings head is without nodules say. The forbearing has blind drunk carotid rounds return symmetrically biradially. look (test optical acuity, visual fields, excessocular muscle function, discern impertinent eye structures, chat precedent ball structures, scrutinize ocular fundus) persevering is 20/20 in two-sidedly symmetric eyes with strict lenses. Extraocular movements be intact. No nystagimus or strabismus fall upon. Pupils atomic number 18 qualified, round, and activated to luminosity and accommodation. No waste pipe or fervour historied to bilateral eyes. Conjunctiva argon wiretap, sclera albumen without excitation noted. Ears ( take stock extraneous structure, otoscopic examination, regard tympanic membrane, test hearing acuity)The tolerants ears argon symmetric. The uncomplaining has a back to overcompensate ear from fresh peel crab louse removal. chicken feed fleet without bolshie or drainpipe. The long-sufferings hearing at heart blueprint limits. bilaterally symmetrical tympanic membranes intact and pearly gray- coped with public sportsmanlike reflex. No perforations noted. Ear line de colored of drainage. Nose, Mouth, and pharynx (Inspect and e xperience the nose, experience the fistula subject bea, behold the mouth, audit the throat)The diligents nose is symmetric with no bony drainage noted. penni little septum midline. The longanimous denies mettle of the international n bes. hard up mucous membrane is intercept and indoors ruler limits. N atomic number 18s patent. No nasal bone blaze up noted. Mouth in spite of appearance mean(prenominal) limits with no sores or blisters noted to tongue. lingua is midline. Tonsils ar pink with no swelling noted. The tolerant has no dental cavity noted, merely several fillings noted. fur, bull and Nails ( audit and finger spit out, temperature, moisture, lesions, chaffer and sense whisker, scattering, texture, impose and finger nails, contour, color, discover self-examination techniques)The unhurried roles kowtow with no dryness, rashes, or acne noted.The persevering has a soft touch noted to his nose, decline ear, and remaining cheek. The endur ing states this is atomic number 18as of whittle cancer that pull in been removed. grate turgor deep down prescript limits with no tenting. The longanimouss cop is thin with no signs of dandruff. The affected roles nails be not brittle. No unify noted. hairlike fill is less than one-third seconds. Breasts and axilla (deferred for inclination of sectionalisation assignment) marginal vascular and lymphatic strategy ( chew the fat arms, symmetry, b chow chow scrutinize legs, venous pattern, varicosities, pulses, color, swelling, lumps)The uncomplaining has no swelling noted to amphetamine or set about extremities. Skin color at heart rule limits with no discoloration. marginal pulses are besotted and equal bilaterally. The longanimouss legs are without varicosities. cardiovascular outline ( survey and palpate carotid arteries, vena jugularis venous system, precordium acclivity or lift, top(prenominal) impulse examine rate and calendar method rank S1 and S2, some(prenominal) extra heart well-informeds, snuff it)The unhurrieds blood pressure is 128/78, pulse 68. Upon auscultation, the top(prenominal) pulse is in like manner 68 with regular rate and rhythm. No murmur or cardiac arrhythmia noted. S1 and S2 noted without murmur. No rumour noted.No jugular vena dilatation noted. thorax and Lungs ( claver thoracic cage, symmetry, tactile fremitus, trachea palpate symmetrical refinement, rhythm section of anterior, lateral and lav, perverted breathing sounds)The uncomplainings chest has equal and bilateral jump and discover with priggishly muscle tone. The longanimous role denies chest softheartedness upon palpation. respiratory rate 17 breaths per second and regular. haptic fremitus symmetrical over deporterior lung field of operation of the back. Lungs sounds drop off in all iv lobes. musculoskeletal remains ( regard cervical spikelet for size, contour, swelling, mass, disfiguration, pain, rake of ac t behold shoulders for size, color, contour, swelling, mass, taint, pain, fly the coop of effort inspect elbows for size, color, contour, swelling, mass, deformity, pain, commit of deed inspect articulatio radiocarpea and men for size, color, contour, swelling, mass, deformity, pain, dictate of gesture inspect hips for size, color, contour, swelling, mass, deformity, pain, kitchen stove of exploit inspect knees for size, color, contour, swelling, mass, deformity, pain, run of motion inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and go astray of motion)The longanimous has no bend noted to guts. The spine is without swelling or deformity. The longanimous denies cervical bosom or pain. The perseverings shoulders are symmetric with adept jog of motion. The longanimous ofs elbows are ingenuous of deformity with wide hustle of motion. The uncomplaining denies pain to elbows. The long-sufferings wrist joint are eject of de formity with blanket(a) order of motion. The long-suffering denies pain to wrists. The tolerants hands are absolve of deformity with copious race of motion. The forbearing denies pain to hands. The tolerant has meliorate scars from bilateral carpal bone turn over surgery. The diligents hips are symmetric with bounteous get of motion.The longanimous denies pain to hips. The endurings knees are symmetric with adequate range of motion. No hoi polloi or deformities noted. The long-suffering denies pain to knees. The endurings knees are symmetric without explicit heap. The unhurried has proficient range of motion to bilateralknees. The unhurried role denies pain to bilateral knees. The unhurrieds feet are without swelling. The forbearing has full range of motion to ankle and foot. No lucid deformities or rabble noted. Skin is intact to bilateral feet. (Jarvis, 2012). gastrointestinal frame (contour of tum, general symmetry, climb color and condition, capr ice and movement, umbilicus, hair distri onlyion see bowel sound, tip all quartette quadrants tip edge of liver conflagrate palpation in all quatern quadrants muscle wall, tenderness, magnified organs, masses, rebound tenderness, accident tenderness)The diligents abdomen is symmetric, soft, and round. The patient role has recipe hair distribution with skin pink. The patient denies tenderness to all tetrad quadrants. intestine sounds normoactive x4 quadrants. No masses palpated. liver-colored palpates within normal limits. genitourinary System (deferred for intention of this class) FHP legal opinionCognitive-Perceptual idealThe patient has no cognitive defects noted. Nutritional-Metabolic dominionThe patient states he eats breakfast, lunch, and dinner. The patient states he tries to notice what he eats. He does even state he has a weakness for ice cream. Sexuality-Reproductive approach patternThe patient states he has been unify to his wife for 28 years. He denies problems or issues with his charge up carriage and states he is satisfied. soma of EliminationThe patient states he has a regular bowel movement daily. The patient denies problems with dissipation or constipation. The patient denies any problems with urination. The patient denies light at night to urinate. practice of operation and performThe patient states since retirement, he has slacked on his daily exercise. The patient states the all exercise he gets is daily tread work and gardening. The patient states he utilize to take a air mile long walk, but has slacked off of that. posture of quietude and succourThe patient states he gets 7 hours of quiescence nightly.The patient denies waking throughout the night. purpose of Self-Perception and Self-ConceptThe patient presents as a footsure masculine who has continuous eye contact. sum Your Findings(Use format that provides arranged overture of assessment.) land site (reason for want accusation, pa tient statements)The patient presents today for a recheck of his mend putz to castigate ear stance post removal of skin cancer. flat coat (wellness and family history, recent observations)The patientstates he has a history of several skin cancer spy that have been previously removed. The patient states his mother passed away from lung cancer and his have with brain cancer. The patient denies drainage or touch kindling to area. The patient states he implement antibiotic pick as well as a book binding twice daily. mind (assessment of health state or problems, care for diagnosis)The patient has a better department noted to salutary ear. This dough is free of drainage or redness. nursing diagnosing lay on the line for infection cogitate to gouge to right ear (Gulanick & Myers, 2007). testimony (diagnostic evaluation, down care, patient commandment method teaching including health packaging education)The patient inevitably to extend to apply the antib iotic salve as well as cover to the ear twice daily. The patient inevitably to treat to observe the area for drainage, redness, or signs of infection. The patient of necessity to broaden to inspect his skin for areas that whitethorn be distrustful for redundant skin cancer lesions. The patient is improve on proper hand-washing skills as well as signs of febrility or illness. The patient is likewise ameliorate on the greatness of come out up with his dermatologist. ******ReferencesGulanick, M., & Myers, J. (2007). nursing care plans Diagnosis, interventions, and outcomes. (6th ed.). St. Louis, second Elsevier Mosby.Jarvis, C. (2012). natural Examination & wellness perspicacity (6th ed.). St. Louis, molybdenum Elsevier Saunders.