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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).
o 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.
o 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)
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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, Massachusetts


School of Nursing

Midlife 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 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).
o 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, NH

Age: 56

Marital status (single, married, partnered,


divorced)) Married
Occupation (current &/or past):
Loss Prevention Manager/ Retail store
Manager
Religion if any: Catholic

Race/ethnicity: Caucasian
Language(s) spoken: English

Do you have health insurance?

Environmental substances?
Food?

Advanced directives (examples: living will,


health care proxy, etc.): None

YES NO If you have health insurance is it adequate? _______________________________-

Allergies: 2 Possible Points_______


Do you have any allergies to:
you do for your allergies?
Medications?
YES NO
Latex?

Gender: Female

YES

NO

YES

NO

YES

NO

If yes, describe the reaction:

Pollen, ragweed. Pt states:


itchy and runny nose.

Current Medications: 3 Possible Points_______


What medications are you taking?
Medication name (include
Purpose of medication?
prescribed, herbs, vitamins,
hormones & over the counter):
Sumatriptan
Migraine

What do

Pt states: I take OTC allergy


medication Alavert.

What is the strength and how


often do you take?

Any side effects or difficulties?

500 mg 4x total a day during


episodic migraine

Sleepiness

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Equate Brand
Multivitamin

Pt states:No side effects.

Iron supplement

Bone & heart health, immune 1 tablet a day


health & energy metabolism,
reproductive system and
healthy skin.
1 tablet a day

Natural sleep aid

Insomnia

Pt states:No side effects.

Pt states:No side effects.

1 tablet every might

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: 9

5 years ago? 7

How do you expect to


rate your health in 5
years? 8

What do you believe causes health and illness?


Have you had any past health problems? (Include illnesses,
accidents, injuries, childhood health care problems,
hospitalizations, and operations with dates)
Do you have any current health problems? If so, describe:

Pt states: Poor eating habit.


Migraine
Lymph Node on right shoulder area removed 1997
C-section 11/92
Infected lymph node removed 09/2012
Heat exhaustion 08/2013
Migraine since 1996
Insomnia since 1993
Allergies ( seasonal allergies, pollen and ragweed)

If you have any current health care problems, please answer the Pt states: Migraine runs in the family, and migraine also stress
questions below: (Reminder: OPQRSTU all positive findings) related.
Pt states: Migraine should be treated with medications, and change
What do you believe caused your health problem?
How do you believe your health problem should be of environment (dark quite area).
Pt states: I have to stop my activities and lay down. It has to be
treated?
quite and dark.
How has this affected your normal daily activities? Pt has no difficulty in caring for themselves and others.
Are you having any difficulties in caring for yourself
or others at home because of this health problem?
o If yes, explain

Health Management and Habits


What do you do when you have a health problem?

on severity pt states: Manageable by


medication or change of environment. If severe pt states:
Physician visit.
Pt states: When s/s become worse or current OTC dont
work.
Depending

When do you seek nursing or medical advice?


How often do you usually go for professional exams:
Physical exam:
Dental exam:
Gynecology exam and pap smear if female:
Have you ever had the following:

YES

Mammogram?
Blood pressure screening?
Colonoscopy?

Other? EKG
What activities do you believe keep you healthy?
Contribute to illness?

Once a year
Twice a year
Once a year
NO

Date of last screening? What were the results?


09/12/2013
Negative
120/70

06/20/2013

Normal, no unexpected findings.

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.
Do you use:
YES
NO

Alcohol?

Tobacco?

Drugs?
Are you exposed to pollutants/ toxins?

When were your last immunizations?


2008

Pt states: Self breast exam.

Have you had a pneumonia vaccine?


(recommended for people over 65 or with a
serious chronic illness)

If yes, describe the amount and time used.

Describe:
Are all of your immunizations up
to date? (ex: Tetanus, Hep B,
Annual Flu vaccine)
Date:

YES

NO

Accident Prevention/Safety/ Environment


YES
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?

NO

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)

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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 Intake
Describe 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?

None

1 or 2

Fruits, vegetables, greens

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

3 or 4

5 or more

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
Who buys the food? Pt buys food.

NO

Do you have enough economic means to purchase 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:

YES

Have you ever gone on a weight reducing diet?

NO

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

Pt states: before no
carbs in diet, but now
low carb.

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 Nails


YES
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.

NO

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.

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ELIMINATION PATTERN 3 Possible Points_______


Bowel Habits
YES

NO

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 Habits
How frequently do you urinate?
What is the amount and color of your urine?
Do you have problems with the following: YES

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?
Do you perform Kegel exersizes?

NO

Pt states: 4 to 5 times a day.


Pt states: Pale yellow.
If yes, describe.

Pt states: Pain in the lower left groin area.

Pt states: Kegel exercise, in standing.

ACTIVITY-EXERCISE PATTERN 5 Possible Points_______


Activities of Daily Living

Describe 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)

How satisfied are you with these activities


Do you have problems with the following: YES

Bathing, dressing, eating?


Meal preparation?
Shopping, housekeeping, paying
bills, etc?
Does anyone help you with these self care
activities?
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?

NO

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

If yes, describe.

Husband and son

Leisure, exercise and work activities


YES
NO
Describe the leisure activities you enjoy
and how often you are able to do them.
Has your health affected your ability to

enjoy your leisure activities?


Describe those activities that you believe give you exercise?
How often are you able to do this type of exercise?
Is there anything that interferes with your

exercise routine?
If employed describe what you do to make a living
Has your employment affected your

health?
Has your health affected your ability to
work?

Describe.
Going to the movies once a month, walking daily at work, reading
daily, swimming during the summer months.
Pt states: Walking at work, unloading a truck at work and
swimming.
Pt states: Daily.

Pt states: I work in the retail.


Pt states: Migraine related to stress.

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SLEEP-REST PATTERN 2 Possible Points_______


Sleep Habits
Describe 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- 6
10 (10 being the best)?
Do you have problems with the following: YES
NO If yes, describe.

Difficulty falling asleep?

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


Remaining asleep?
Does anything help you fall asleep and/or
Pt states: TV and medication (sleep aid).
fall back to sleep? (Examples: lots of
exercise during the day, medications,
reading, TV, relaxation techniques, music,
milk, alcohol).
Do you ever feel fatigued after a sleep

Pt states: I feel fatigued and agitated, dont wanna face things. Just
period?
wanna go back to bed.
Has your current health or life style altered
Pt states: Stress at work makes it difficult to go to sleep.
your normal sleep habits?
Do you feel your sleep habits have

Pt states: Stress and lack of sleep increases her migraine.


contributed to any health problems you
may have?

SENSORY-PERCEPTUAL PATTERN 2 Possible Points_______


Perception of Senses and pain assessment
Do you have problems with the following: YES
NO If yes, describe.

Pt states:I am nearsighted & farsighted, and I use glasses.


Vision or hearing?

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 Glasses
any of the above problems? (ex.: glasses, contacts, hearing
aids)
Do you have any pain now?

Pt states: No pain.
If so, what brings it on? Relieves it? When does it occur? How Pt states: No pain.
often? How long does it last?
Rate your pain on a scale of 1-10, 10 being the most severe
Pt states: No pain.
pain.
Has your pain affected your activities of
Pt states: No pain.
daily living? If so, how?

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,
Pt states: Read the material and start doing it hands on
watch television, demonstrate, explanations by someone else,
etc)?
Do you ever have difficulty expressing

yourself or explaining things to others?


Are you able to remember recent events

Pt states: I remember important childhood events.


and events of long ago?

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?
Do you participate in any social groups, community or
neighborhood activities?
What do you see as your contribution to your community
and/or society?
Who is the main financial supporter of your family?

Pt states: Yes, it is a quite neighborhood. The community is


friendly and I know a lot of people in my community.
Pt states: I work with the local police department on the effects of
stealing and peer pressure sponsored by by work.
Pt states: Helping local youth to make the right choices.
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?


How do you feel about your family?

Pt states: I make the decision with my husband.

What is your role in your family?

Pt states: I am the support system.

Pt states: Irreplaceable, my family is my life.

Is this an important role?


What is your major responsibility in your family?

Pt states: I am the caregiver, and counselor.


Pt states: Good.

How do you feel about this responsibility?


How does your family deal with problems?
Who is the person you feel closest to in your family?
Who is the most important person in your life and why?
YES

NO

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?

Pt states: We all deal with the problem together. We help each


other.
Pt states: My husband.
Pt states: husband, because he is my partner and everything I do, I
do with him.
Describe:

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

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Disease

YES

NO

If 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:
YES

NO

YES

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:

NO

Describe any yes answers:

Pregnancy History:
Gravida___________
(total # of pregnancies)
MID-LIFE WOMEN

# full Term______
(# carried to term)

#Preterm______ # Abortions/Miscarriages _____

# children living_____

Describe:

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 postmenopausal bleeding?

Male:
YES

NO

YES

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?

NO

Have you had problems with infertility?


Describe any yes answers:

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Male or Female:
YES

NO

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?
What do you consider to be your strengths/ weaknesses?

If yes, describe:

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 systems
YES NO
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 Beliefs
What 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 Beliefs


YES

NO

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)
YES

NO

If current problem, note If problem


date diagnosed and type resolved, note
of condition
date resolved

Alcohol problem
Allergies (type)
Anemia
Anorexia/Bulimia
Arthritis
Asthma
Cancer or tumor

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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) _______________________


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List Client Strengths and Areas of Improvement 9 possible points _____________


Client Strengths

Client Areas of Improvement

Client keep up with annual exam such as


physical, dental and gynecological exam.

Client needs to manage the stress at her work

Client is health conscious and does not


drink or smoke.
Clients diet consist of low carbohydrates

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6

3 Nursing Diagnosis List By Highest Priority 15 Possible Points _______


Nursing Diagnosis

Data to support Nursing


Diagnosis

Rationale for Priority

1.Highest Priority

2.Second Priority

3.Third Priority

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


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6

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

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

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.

Use professional terminologies, correct spelling,


and write neatly in ink or typed. Must use original
form.
Must submit paper copy.

Comme
nts

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Score sheet attached to Health History when


handed in to lab instructor.
Total:

100

Hc2003, kg 2012