Grand Canyon NRS-434V Week 5 Benchmark: Individual Client Health History And Examination Health Assessment of Infants

Children’s and adults’ physical examinations are conducted in a comparable yet separate manner. The act of auscultation, palpation, and vital sign taking to obtain objective data is the same, but the normal range boundaries vary. A healthy adult’s typical blood pressure range is 90/60 mmHg – 120/80 mmHg, pulse rate 60-100 beats per minute, and temperature 97.8’F to 98.6’F, but a 1-11-year-old child’s heart rate is 70-120 bpm, blood pressure is 90-110 systolic and 55-75 diastolic, and temperature is 97.8’F to 98.6′

According to Erikson’s theory, an adult’s stage of development is focused on the fear of loneliness if no long-term relationship exists, and an adult considers their contribution to society with their achievements or lack thereof, whereas a school-aged child’s stage of development is focused on establishing trust and self-esteem (Grand Canyon University, 2018).

and approach with these two age groups are also different. A loving and pleasant setting is essential for a school-aged child’s parents to place their trust in the healthcare professional. The questions are also written in a way that allows the child to react. The adult, on the other hand, is subjected to more factual and direct questions. A thorough and effective evaluation is performed utilizing the evidence-based practice tools offered to the health care team to enhance health and have a successful nursing process.

Grand Canyon University

In this assignment, you will be completing a health assessment on an older adult. To complete this assignment, do the following:

1. Perform a health history on an older adult. Students who do not work in an acute setting may “practice” these skills with a patient, community member, neighbor, friend, colleague, or loved one. (If an older individual is not available, you may choose a younger individual).
2. Complete a physical examination of the client using the “Individual Health History and Examination Assignment” resource. Use the “Functional Health PatternAssessment” resource as a guideline to assist you in completing the template.
3. Document findings of complete physical examination in Situation-Background-Assessment-Recommendation (SBAR) format. Refer to the sample SBAR Template located on the National Nurse Leadership Council website at www.ihs.gov/NNLC/documents/resources/SBARTEMPLATE.pdf.
4. as a guide. Document the findings of the physical examination in the assessment worksheet.
5. Using the “Individual Health History and Examination Assignment” resource, provide the physical examination findings summary with planned interventions for the client. Include any community services in the interventions.

APA format is not required, but solid academic writing is expected.

HEALTH ASSESSMENT – WELL OLDER ADULT

DEMOGRAPHICS:

Initials:            DOB:              Marital Status:  Married

Gender:                         Ethnicity/Culture:  Caucasian

Health Insurance: Blue Chip Medicare          Dental Insurance:_______________

CURRENT HEALTH STATUS:

JH considers him self to be a somewhat health person besides his illness and hospitalization 2 years ago.  To stay healthy, JH admits to exercising regularly and being aware of his diet.  He admits to visiting a health care provider regularly and attends cardiac rehab twice per week.  JH admits that his health has been very good over the past year as he continues to recover from his heart disease. In early 2012, he had been hospitalized for two months with an infection around his heart.  Patient admits to smoking in the past but quit two years ago. He continues to drink a couple glasses of red wine at dinner everyday.  Patient takes a prescription medication for his Blood Pressure along with OTC antacids and allergy medications but does not remember the names.  JH is allergic to pollen, walnuts, dust and mold.  He admits to being UTD on all medications including influenza, shingles, hepB and pneumococcal.  Patient wears his seat belt every time he is in the care and has never had any accidents nor been involved in one.  He denies knowing first aid/CPR.

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FUNCTIONAL HEALTH PATTERNS:

ACTIVITY/EXERCISE:

JH attends cardiac rehab twice a week, exercising on the recumbent bike, hand weights and sometimes the treadmill.  He does not like using the treadmill.  His leisure activates used to include skiing but since his hospitalization he has slowed down on this activity. He now enjoys sailing in the summertime.  JH has a shoulder pad prosthesis since the amputation of his right clavicle/ scapula for osteosarcoma in 1962.  He denies needing a cane, walker or wheelchair.

SLEEP/REST :

JH  admits to sleeping 6.5-7 hours per night and wakes up feeling rested.  He denies napping during the day.  He retires at 9:30pm and awakens at 4:45am.  He denies any problems with sleeplessness and the used of sleep aids.

CARDIOVASCULAR/RESPIRATORY:

BP:120/60                     Radial Pulse:_________       Rhythm: A-fib/flutter

Respirations:  18

JH admits to chest pain and SOB.  He denies cough, distended neck veins, edema, cyanosis and varicosities.

NEUROMUSCULAR/COGNITION:

JH speaks English.  He claims he used to have bad migraines but doesn’t anymore.  He has had 2-3 seizures a couple years ago but has been sense treated.  Patient admits to having balance problems in the past. He wears glasses for reading.  JH denies problems with dizziness, speech impediment, walking and visual problems.  He does not use a hearing aid.  UTA date of last hearing or eye exam.  He denies any problem with memory.

NUTRITIONAL/METABOLIC:

Height: 6’2.5”  Weight 165 lbs

JH eats three full meals a day and denies snacking.  He admits to not drinking enough water.  He does not have dentures but has crowns. His last dental exam was a couple months ago.  He denies weight loss and weight gain.  JH is allergic to walnuts.  He denies GI bleeding, difficulty swallowing, nausea, vomiting, anorexia and bulimia.

SELF-PERCEPTIONS/COPING/

JH’s friends would describe him as friendly, positive and sometimes funny.  His source of strength and hope comes from God and his family and friends.  He attends church at least once a week but often times multiple times per week.

PH admits that his health problems have affected his skiing but he has not stopped completely.  He denies feelings of anger, fear, anxiety and depression but says the biggest negativity in his life is his impatience.  He deals with this but just brushing it off and occasionally swearing.  The only significant loss/change in this life was his hospitalization two years ago.  If he could changes one thing to improve his quality of life it would be to be more generous.

CULTURAL ASSESSMENT

Patient denies his cultural background affecting his health care needs.  He is Caucasian with his cultural background being English and Irish. His family shows they care by giving hugs and kisses.

ILLNESS BELIEFS AND CUSTOMS

JH said that people become ill when they are ill or when there is a lot of tension.  When he is sick, he likes to pray, relax and tries to be patient,  When his loved ones are sick he prays for them, cares for them and is there for them.

INTERPERSONAL RELATIONS

JH defines his family as terrific.  He has four adult kids and a wife of 47 years.  He denies specific duties for men women and children in a family. Growing up both him and his wife disciplined the children but now they live alone and take care of themselves and their families.  JH admits that the most important aspect of life is leading a good life full of gratitude.  There are no topics not discussed in their household.  In his home they only speak English.  JH is a self-employed attorney. He admits to finances influencing his life.  He graduated form law school. His wife and three of his children graduated from college one having his doctorate.

Individual Client Health History And Examination Health Assessment of Infants Rubric
Course Code Class Code Assignment Title Total Points
NRS-434VN NRS-434VN-O502 Developmental Assessment and the School-Aged Child 100.0

Criteria Percentage Unsatisfactory (0.00%) Less than Satisfactory (75.00%) Satisfactory (79.00%) Good (89.00%) Excellent (100.00%)
Content 80.0%
Comparison of Physical Assessment Among School-Aged Children 25.0% A comparison of physical assessments among different school-aged children is omitted. An incomplete comparison of physical assessments among different school-aged children is summarized. How assessment techniques would be modified depending on the age and developmental stage of the child is omitted or contains significant inaccuracies. A general comparison of physical assessments among different school-aged children is summarized. How assessment techniques would be modified depending on the age and developmental stage of the child is generally described. More information or support is needed for clarity or accuracy. A comparison of physical assessments among different school-aged children is presented. How assessment techniques would be modified depending on the age and developmental stage of the child is described. Some information is needed for clarity. A detailed comparison of physical assessments among different school-aged children is presented. How assessment techniques would be modified depending on the age and developmental stage of the child is thoroughly described. Insight is demonstrated into the physical assessment of school age children.

Typical Assessment for a Child of a Specific Age 25.0% The typical developmental stage of a child between the ages 5 and 12 is not described. The typical developmental stage of a child between the ages 5 and 12 is summarized. The summary contains significant inaccuracies for the age of the child. The typical developmental stage of a child between the ages 5 and 12 is generally described. The description contains some inaccuracies for the age of the child. The typical developmental stage of a child between the ages 5 and 12 is described. The overall description is accurate. Some information is needed for clarity. The typical developmental stage of a child between the ages 5 and 12 is accurately and thoroughly described.
NRS-434 Developmental Assessment and the School-Aged Child Rubric
Developmental Assessment of a Child Using a Developmental Theory (Erickson, Piaget, Kohlberg) NRS-434 Developmental Assessment and the School-Aged Child Rubric 30.0% A child assessment based on a developmental theory is omitted. A child assessment based on a developmental theory is partially summarized. Partial strategies to gain cooperation and for how explanations would be offered during the assessment are presented. The potential findings expected from the assessment are omitted or are incorrect. There are significant inaccuracies. A child assessment based on a developmental theory is generally described. General strategies to gain cooperation and for how explanations would be offered during the assessment are presented. The potential findings expected from the assessment are summarized. There are minor inaccuracies. A child assessment based on a developmental theory is described. Appropriate strategies to gain cooperation and for how explanations would be offered during the assessment are presented. The potential findings expected from the assessment are described. Some information is needed for clarity. A child assessment based on a developmental theory is thoroughly described. Well-developed strategies to gain cooperation and for how explanations would be offered during the assessment are presented. The potential findings expected from the assessment are all accurate and described in detail.

Organization and Effectiveness 15.0%
Thesis Development and Purpose 5.0% Paper lacks any discernible overall purpose or organizing claim. Thesis is insufficiently developed or vague. Purpose is not clear. Thesis is apparent and appropriate to purpose. Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose. Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

Argument Logic and Construction 5.0% Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources. Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility. Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis. Argument shows logical progressions. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative. Clear and convincing argument that presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

Mechanics of Writing (includes spelling, punctuation, grammar, language use) 5.0% Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, or word choice are present. Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. Writer is clearly in command of standard, written, academic English.

Format 5.0%
Paper Format (use of appropriate style for the major and assignment) 2.0% Template is not used appropriately or documentation format is rarely followed correctly. Template is used, but some elements are missing or mistaken; lack of control with formatting is apparent. Template is used, and formatting is correct, although some minor errors may be present. Template is fully used; There are virtually no errors in formatting style. NRS-434 Developmental Assessment and the School-Aged Child Rubric All format elements are correct.

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) 3.0% Sources are not documented. Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors. Sources are documented, as appropriate to assignment and style, although some formatting errors may be present. Sources are documented, as appropriate to assignment and style, and format is mostly correct. Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.
NRS-434 Developmental Assessment and the School-Aged Child Rubric
Total Weightage 100%