HEALTH ASSESSMENT

A. HISTORY TAKING:

1. IDENTIFICATION DATA:
 Name- Anita Santra
 Age- 45yrs
 Sex- Female
 Religion- Hinduism
 Home address- Vill- Biramnagar, PO-Paltagarh, PS-Singur, Dt-Hoogly

2. HISTORY OF ILLNESS:

 Present illness- Nothing significant

 Past illness- Hysterectomy done 5yrs back
 Medical history- Suffering from acidity sometimes
 Surgical history- Hysterectomy done 5yrs back
 History of hospitalization- 5yrs back for Hysterectomy

3. PERSONAL HISTORY:

 Marital status- Married

 Language- Bengali
 Educational qualification- MP
 Occupation- House wife
 Life roles & responsibilities- Homemaker
 Satisfaction or dis-satisfaction in family/ work/social relationships- Satisfied.
 Habits- No addiction, Healthy habit.
 Hobby- Stitching
 Usual food & fluid intake- Adequate
 Appetite- Good, sometime suffering from acidity
 Daily eating time- Morning tea 7am, Breakfast 10am, Lunch 2pm, Evening tea 6pm
Dinner 10.30pm.
 Food restrictions/preferences/food supplements-Nothing
 Allergies in food/drug- Nothing
 Swallowing, chewing or eating problems- Nothing
 Bowel and bladder pattern- Regular
 History of immunization- Not available
 Menstrual history( for female client)-
 Age of menarchy- 13yrs
  Duration- Hysterectomy done
 Regular/Irregular- NA
 Dismenorrhoea-NA

4. FAMILY HISTORY:

 Type of family-Nuclear family

 No. of family member- 04
 Composition of the family –

SL.NO Name of Relation Age Sex Educational Occupation Health

the with qualification status of the
member client member
1 Sajal Husband 47yrs Male VIII pass Farmer Healthy
Santra
2 Anita Self 45yrs Female MP House wife “
Santra
3 Moumita Daughter 20yrs Female Studying Student Pale
Santra BA 2nd year conjunctiva,
weakness
4 Pritha Daughter 16yrs Female Studying Student Healthy
Santra class XI

 Total income of the family- 10,000/-

 One day dietary pattern of the family-
 Rice/chapatti- Rice
 Cereals- Dal
 Vegetables- takes all type of vegetables
 Fish/meat/chicken/egg-per day/per week/per month- Weekly as per their ability.
 Milk- taken occationally.
 Fruit- Locally available fruits taken sometimes.

5. PSYCHOSOCIAL HISTORY:

 Caring for clients- Good

 Family interaction/ support system- Good family support
 Social relationship/ support- Present
 Cultural influence- Belief in God
 Adherence to healthy practice- Apparently present
 Coping mechanism- uses some coping mechanism
 Presence of life stress- Absent
 Milestone development- Well developed
  Lifestyle-
 Dietary pattern- vegetarian/non-vegetarian
 Sleeping pattern- regular/irregular/any sleep disorder
 Pattern of exercise- House hold activity & some walking
 Belief in GOD/not- Have belief
 Rituals & practices- Follows the rituals & practices

6. ENVIRONMENTAL HISTORY:

 Living area- urban/rural

 Housing condition- kancha/pacca
 Layout of rooms- well ventilated/not
 Supply of drinking water- Direct water from Submarshal
 Supply of water for bathing & household work-Tap water
 Supply of electricity- Present
 Waste/ excreta disposal- Dumping/ Sanitary latrine present
 Working environment- House environment is clean & good.

B. PHYSICAL EXAMINATION:

1. GENERAL APPEARANCE:

 Body build- Obese(BMI-29)

 Emotional state- Normal
 Oriented to time/place/person-Oriented
 State of consciousness- Fully conscious
 Speech- Normal
 Body movement- Normal
 Clothing- Wear saree

2. MEASUREMENT:

 Hight- 153cm
 Weight- 68kg
 Vital signs-
Temperature- 97.6 degree F
Pulse- 76bts/min
Respiration- 20brs/min
Blood pressure- 110/76mm of hg

3. HEAD TO FEET EXAMINATION:

Head-

 Shape & symmetry of skull- Normal shape, symmetry present

 Masses- Not present
 Tenderness- Not present
 Scalp- some dandruff present
 Hair distribution- Normal
 Color & texture-Normal
 Presence of pediculosis/dandruff- some dandruff present
 Clean/unclean- Clean

4. INTEGUMENTARY SYSTEM:

 Clean/unclean- Clean
 Color or texture change- No
 Temperature- Normal
 Turgor- Normal
 Condition- Good
 Abnormal hair growth on skin- Nil
 Nails- Clean & small
 Any abnormal sign in nail beds- Nil
 Capillary refill of nails-3-5sec
 Any sign of poor circulation in nail beds-Nil

5. FACE:

Any sign of paralysis/facial palsy- No

Eyes:
 Symmetry/not- Symmetry
 Clean/sign of infection/presence of discharge- Clean
 Position & movement of eyelid- Normal
 Visual fields- Normal
 Extra ocular movements- Nil
 Eye brows- Normal
 Conjunctiva- Normal
 Condition of cornea & sclera- Apparently normal
 Pupils- Normal
 Vision- Normal
 Any vision abnormality- Nil
Nose:

 External nose- Normal

 Internal nose- Normal
 Any septal deviation- Nil
 Frequency of colds- Very often
 Sinus pain/sense of smell – No pain, well sense of smell

Ears:

 Placement- Normal
 Pinna- Normal
 Auditory canal- Clean & normal
 Pain/tinnitus- Nil
 Discharge- Nil
 Hearing loss- Nil
 Vertigo- Nil
 Clean /any obstruction- Clean

Throat & mouth:

 Lips- Moist & pink

 Buccal mucosa- Normal
 Teeth- Normal
 Palates/floor of mouth- Normal
 Frequent sore throat- Not present
 Hoarseness or change in voice- Nil
 Bleeding or swelling of gums- Absent
 Soreness of tongue or gum- Absent
 Gag reflex- Present
 Tonsils- Normal

Extremities:

 Size & shape- Normal

 Symmetry/deformity/involuntary movements- Absent
 Arms/fingers/wrists/elbows/shoulders for- Normal
6. POSTERIOR THORAX & ANTERIOR THORAX( RESPIRATORY &
CARDIOVASCULAR SYSTEM):

Muscular development/ respiratory movement- Normal

Approximation of AP diameter- 90cm

Breast for configuration/ symmetry/dimpling of skin- According to her statement Nil

Palpate breasts/BSE- She is not co-operate

Palpate axilla

Chest & lungs-

 Pain related to respiration- Nil

 Dyspnoea/cyanosis/wheezing- Absent
 Cough/ sputum- No cough
 Exposure to tuberculosis- No

Heart & blood vessels:

 Precipitating causes for chest pain/distress- Nil

 Dyspnoea/orthopnoea/hypertension/exercise of activity tolerance- Nil
 Auscultate for rate & rhythm- Normal
 Character for s1 & s2 sound- Audible

7. GASTROINTESTINAL SYSTEM:

 Size- unable to measure

 Condition of umbilicus- Normal
 Liver- Not palpable
 Spleen- Not palpable
 Bowel regulation- Bowel habit normal
 Hemorrhoids- Not present

8. NEUROLOGICAL:

 Syncope/seizures/weakness or paralysis- Not present

 Abnormalities of sensation/coordination- Nil
 Tremors- Nil
 Loss of memories- Nil
  Spine- No abnormality present

9. GENITOURINARY SYSTEM:

 Kidney- No abnormality
 Urinary bladder- No abnormality
 Micturation- Normal & regular
 Sexually transmitted disease- Not present
 Inspect perineum/rectum- She is not cooperate.

Signature of Supervisor Signature of Student

SUB: ADVANCE NURSING PRACTICE

HEALTH
ASSESSMENT

SUBMITTED TO SUBMITTED BY
Ms. S. PODDER RUMA GHOSH
PROFESSOR 1st YEAR
GOVT.COLLEGE OF NURSING M. Sc NURSING STUDENT
ID & BG HOSPITAL CAMPUS GOVT. COLLEGE OF NURSING
ID & BG HOSPITAL CAMPUS
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