NR304 Health History and Physical Assessment Paper Example (Paragraph Format, Erikson, Reflection)

NR304 Health History and Physical Assessment Guidelines

Purpose: Before implementing or evaluating any nursing plan of care or intervention, the nurse assesses the individual by collecting both subjective and objective data. This assignment focuses on collecting subjective assessment data, synthesizing the data, and identifying health/wellness priorities based on the findings. The purpose is two-fold: to recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and developmental) affecting health and wellness, and to reflect on the interactive process between self and client when conducting a health assessment.

Important formatting requirements: Assignments submitted in bullet point format will receive a zero. All sections must be written in paragraph format with a minimum of 3 sentences per section. Omission of Review of Systems information will result in an automatic unsatisfactory grade for that section.

Complete a health assessment/history on an individual 18 years of age or older who is NOT a family member or close friend, keep the information confidential and use only initials. Required sections:

• Health History Assessment (30%): demographics; perception of health; past medical history (childhood illnesses, accidents or injuries, chronic illnesses, hospitalizations and operations, obstetric history, immunizations, last examination including dental, allergies, current medications and substance use); family medical history; review of systems.
• Physical Examination: Objective Data (20%): HEENT, neck, respiratory, cardiovascular (NR302); neurological, gastrointestinal, musculoskeletal, peripheral vascular (NR304).
• Needs Assessment (20%): developmental considerations using Erikson’s stages (cited), cultural considerations, psychosocial considerations, collaborative resources to improve health.
• Reflection (20%): the interaction holistically; comparison with what you learned; barriers to communication; what went well; unanticipated challenges; information you wished you had; how you will alter your approach next time.
• Style and Organization (10%): grammar, clear reasoning, APA in-text citations and reference page; minimum one resource for the Erikson section.

Health History Assessment

Demographics. The interviewee, J. M., is a 46-year-old woman who was born in Kingston, Jamaica, and moved to the United States at age 19. She identifies as female and uses she/her pronouns, is married, and identifies her race as Black and her ethnic origin as Jamaican. She works full time as an administrative assistant at a community college, and her primary language is English. The client provided the history herself, and she was alert, cooperative and appeared to be a reliable historian.

Perception of health. J. M. describes her health as “fair to good,” explaining that she feels well most days but worries about her blood pressure and weight. She defines being healthy as “having the energy to work, cook for my family and go to church without feeling tired.” She stated that her main health goals are to lower her blood pressure without adding more medications and to lose 15 pounds before her next checkup. She believes that stress at work and limited time for exercise are the biggest barriers to better health.

Past medical history. J. M. reported having chickenpox and frequent ear infections as a child, with no serious childhood illnesses. She denied any history of motor vehicle accidents, fractures, head injuries, burns or concussions but reported a sprained right ankle from a fall on stairs at age 38. She was diagnosed with hypertension at age 41 and prediabetes at age 44, and she was hospitalized once for a laparoscopic cholecystectomy at age 40, without complications. Her obstetric history is Grav 2, Term 2, Preterm 0, Ab 0, Living 2, with two vaginal deliveries and gestational hypertension during her second pregnancy. She reported that her immunizations are up to date, including a tetanus-diphtheria-pertussis booster four years ago, an annual influenza vaccine and a COVID-19 vaccine series, and she has not yet received a shingles vaccine. Her last physical examination was eight months ago, and her last dental cleaning was one year ago. She has an allergy to sulfa drugs, which caused a rash, and seasonal allergies to pollen, and she denied food or latex allergies. Her current medications are lisinopril 10 mg by mouth daily, loratadine 10 mg daily as needed for seasonal allergies and a daily multivitamin. She denied tobacco and street drug use and reported drinking one glass of wine about twice a month.

Family medical history. J. M.’s maternal grandmother had type 2 diabetes and died of a stroke at age 72, and her maternal grandfather died of prostate cancer at age 70. Her paternal grandparents’ health history is unknown because she had little contact with them. Her mother, age 68, has hypertension and type 2 diabetes, and her father, age 70, has hypertension and had a myocardial infarction at age 64. She has one brother, age 50, who has hypertension and obesity, and one sister, age 43, who is healthy. Her two children, ages 17 and 13, are healthy except that her younger child has mild asthma. This history shows a strong family pattern of hypertension, diabetes and cardiovascular disease.

Review of systems. J. M. denied fever, chills or unintentional weight loss but reported a gradual weight gain of 10 pounds over the past two years and occasional fatigue in the afternoon. She denied changes in skin, hair or nails, headaches, dizziness, vision changes other than needing reading glasses, hearing loss, ear pain, nasal congestion outside allergy season, sore throat or difficulty swallowing. She denied cough, shortness of breath, wheezing, chest pain, palpitations or swelling of the legs. She denied nausea, vomiting, abdominal pain, diarrhea, constipation, blood in the stool or heartburn, and she reported regular bowel movements daily. She denied urinary frequency, urgency, burning or incontinence and reported regular menstrual periods that have become slightly irregular in the past year. She reported occasional lower back stiffness after long periods of sitting but denied joint swelling, weakness, numbness, tingling, seizures or memory problems. She reported feeling stressed at work at times but denied persistent sadness, anxiety or sleep problems, sleeping about six and a half hours per night. She denied excessive thirst, heat or cold intolerance, easy bruising, bleeding or swollen lymph nodes.

Physical Examination: Objective Data

General and vital signs. J. M. appeared well groomed, alert and oriented to person, place, time and situation, and in no acute distress. Her vital signs were blood pressure 138/86 mm Hg in the right arm while seated, heart rate 78 beats per minute and regular, respiratory rate 16 breaths per minute, temperature 98.4°F orally and oxygen saturation 98% on room air. Her height was 5 feet 4 inches and weight 182 pounds, giving a body mass index of about 31.2, which is in the obese range.

HEENT. The head was normocephalic and atraumatic, with evenly distributed hair and no lesions or tenderness. The eyes showed equal, round pupils reactive to light and accommodation, intact extraocular movements, clear conjunctivae and white sclerae. The ears had intact, pearly gray tympanic membranes bilaterally, and the whisper test was normal. The nasal mucosa was pink and moist without discharge, the oral mucosa was pink and moist, the teeth were in good repair, and the tonsils were 1+ without exudate.

Neck. The neck was supple with full range of motion and the trachea was midline. The thyroid was not enlarged, and no nodules or tenderness were palpated. No cervical, submandibular, supraclavicular or other lymph nodes were palpable.

Respiratory system. The chest was symmetric with equal expansion and no use of accessory muscles. Tactile fremitus was equal bilaterally, and percussion was resonant throughout. Breath sounds were clear and vesicular in all lung fields without crackles, wheezes or rhonchi.

Cardiovascular system. The apical pulse was palpated at the fifth intercostal space at the midclavicular line, with a regular rate and rhythm. S1 and S2 were clearly heard without murmurs, rubs, gallops or extra sounds. There was no jugular venous distension, and carotid pulses were 2+ and equal without bruits.

Neurological system. J. M. was alert and oriented, with clear speech and intact recent and remote memory. Cranial nerves II through XII were grossly intact, and sensation to light touch was intact in all extremities. Strength was 5/5 in all extremities, deep tendon reflexes were 2+ and symmetric, and gait, Romberg test and finger-to-nose coordination were normal.

Gastrointestinal system. The abdomen was round and soft, with well-healed laparoscopic scars and no visible masses or pulsations. Bowel sounds were active in all four quadrants, and percussion revealed tympany over most areas. Light and deep palpation revealed no tenderness, masses or organ enlargement.

Musculoskeletal system. The spine had normal curvature, and joints showed no swelling, redness or deformity. Range of motion was full in all major joints, with mild stiffness reported on lumbar flexion but no pain. Muscle strength was equal bilaterally, and the previously injured right ankle had full range of motion and stability.

Peripheral vascular system. The skin of the extremities was warm, dry and intact, with normal color and no varicosities or lesions. Radial, brachial, femoral, dorsalis pedis and posterior tibial pulses were 2+ and equal bilaterally, and capillary refill was less than 3 seconds. There was no edema, calf tenderness or skin changes in the lower extremities.

Needs Assessment

Developmental considerations. At 46 years old, J. M. is in Erikson’s stage of generativity versus stagnation, which spans middle adulthood and focuses on contributing to the next generation through parenting, work and community involvement (Erikson, 1963; Jarvis & Eckhardt, 2024). She appears to be meeting the milestones of this stage because she is actively raising her two children, mentors student workers at the college and volunteers with her church’s youth program. She expressed pride in “helping young people get started,” which reflects a sense of generativity rather than stagnation. A potential risk is that her many responsibilities leave little time for her own health, which could lead to burnout if she does not balance caring for others with caring for herself.

Cultural considerations. Culture includes the shared values, beliefs, traditions and practices that shape how a person views health and illness. J. M. describes herself as Jamaican American and Christian, and she values family closeness, faith and hard work. She reported using some traditional remedies, such as herbal teas with cerasee or ginger for colds and digestion, alongside prescribed medications, and she said she feels comfortable telling her provider about them. Her traditional diet includes foods such as rice and peas, fried dumplings, salted fish and plantains, which she enjoys but recognizes can be high in sodium and refined carbohydrates. She believes that prayer supports healing and also trusts her health care providers, and she prefers a female provider for gynecological care.

Psychosocial considerations. J. M.’s main support system is her husband, who she said is “very supportive,” and her two children, who help with household tasks. She attends church weekly and describes her church community as a major source of emotional and practical support. At work, she has a good relationship with her supervisor and coworkers, although she reports stress during registration periods. She has stable housing and employer-sponsored health insurance, and she did not report financial strain affecting her health care.

Collaborative resources to improve health. Several resources could help J. M. reach her goals of lowering blood pressure and preventing diabetes. Her health insurance and the college’s wellness program offer a CDC-recognized National Diabetes Prevention Program, which provides a year-long lifestyle change program for people with prediabetes. A referral to a registered dietitian could help her adapt traditional Caribbean recipes using the DASH eating plan to reduce sodium while keeping cultural foods she enjoys. Her church’s health ministry and walking group could support regular physical activity, and a home blood pressure monitor would allow her to track readings between visits. She should also schedule a shingles vaccination, a screening mammogram and colorectal cancer screening, which are recommended for her age group.

Reflection

Interaction holistically. The interview took place on a Saturday morning at 10:00 a.m. in a quiet, private meeting room at a community center, which allowed J. M. to speak openly without interruptions. I began by introducing myself, explaining the purpose of the assignment and assuring her that her information would remain confidential and that only her initials would be used. I sat at eye level across a small table, used open-ended questions and active listening, and summarized her answers to confirm understanding. The full interview and examination took about 75 minutes, and J. M. remained engaged and relaxed throughout.

Comparison with what I have learned. My interaction closely followed what I learned about therapeutic communication, including starting with broad, open-ended questions and then moving to specific closed questions. As our textbook recommends, I began the physical examination with less invasive assessments and explained each step before touching her, which helped build trust (Jarvis & Eckhardt, 2024). However, I realized that in real practice, time limits would require me to be more efficient than I was. I also learned that following a structured format helps ensure that no part of the health history is missed.

Barriers to communication. The main barrier I experienced was my own nervousness, which caused me to focus too much on my notes at the beginning instead of maintaining eye contact. I overcame this by pausing, taking a breath and reminding myself to listen rather than rush to the next question. A second barrier was that J. M. was initially hesitant to discuss her weight and alcohol use, so I normalized the questions by explaining that I ask them of everyone. In the future, I will practice the interview more beforehand and use a structured but flexible guide so I can focus on the person rather than the paper.

What went well. Building rapport went well, and J. M. shared detailed information about her culture, family and goals. She appreciated being asked about her health beliefs and traditional remedies, which helped me understand her as a whole person. The physical examination also went smoothly because I had practiced the sequence in the lab and explained each step clearly.

Unanticipated challenges. One unexpected challenge was obtaining a complete family history, because J. M. did not know her paternal grandparents’ health conditions. Another challenge was managing time, since she enjoyed sharing stories and the interview took longer than I planned. I learned to gently redirect the conversation by summarizing her point and then asking the next question.

Information I wished I had. I wished I had access to her recent laboratory results, such as her hemoglobin A1C, lipid panel and kidney function, which would have helped me better understand her risk for diabetes and cardiovascular disease. I also would have liked to see her previous blood pressure trends to know whether her current reading represented improvement. Without these data, my assessment of her health priorities relied mainly on her self-report.

How I will alter my approach next time. Next time, I will prepare a written interview guide with time estimates for each section so I can stay organized and efficient. I will also ask the interviewee to bring a list of medications and recent laboratory results if available. Finally, I will spend more time on health teaching at the end of the interview, such as discussing the DASH diet, because J. M. showed a strong readiness to learn.

References

Erikson, E. H. (1963). Childhood and society (2nd ed.). W. W. Norton.

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.