NRS-434V Week 5 Benchmark: Individual Client Health History And Examination

Health Assessment – The Health Assessment of Infants

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.

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.

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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.

NRS-434V Week 5 Benchmark: Individual Client Health History And Examination 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%

Assessment is an important practice in nursing. Assessment provides data that nurses utilize in making their diagnoses and appropriate treatment plans for their patients. Assessment methods differ significantly based on the age group of a client. For example, it is anticipated that the physical assessment methods used for a pediatric patient differs significantly from that of an adult patient. Similarly, the assessment tools utilized to determine the care needs of the patients of different ages vary. Therefore, this paper explores the comparison of physical assessments used in school-aged children, their modification, and assessment of a child based on Piaget’s theory of development.

Comparison of Physical Assessment Among School-Aged Children

The assessment of school-aged children differs significantly from that of the toddlers, infants and the preschoolers. School-aged children have an enhanced understanding of the reality unlike infants, preschoolers, and toddlers that live in a world of fantasy. The thinking also differs among them as seen from the fact that school-aged children have developed logical thinking and comprehension of events. They also understand the consequences of their actions. School-aged children also have developed social skills from interacting with others in their societies. As a result, they have curiosity to learn new aspects in their lives and accomplish tasks for recognition. The children at the age group of 5-12 years can also express their health problems as well as their experience with them (Chiocca, 2019). Therefore, the appropriate modification of physical assessment techniques when working with them entails asking the children appropriate questions. It also entails involving the guardians or parents in the assessment process to obtain adequate data to inform the treatment plans. An additional modification entails beginning the assessment with areas that the children have a high level of awareness and moving to complex aspects of care (Tagher & Knapp, 2019).

Typical Assessment for a Child of a Specific Age

The selected case study involved a seven-year-old female patient brought to the clinic by her parents for assessment. The patient was brought for the annual normal checkup. She was born through caesarian surgery and with an Apgar score of 10. The immunization history is up-to-date with developments appropriate for her age. She does not have any history of surgeries or hospitalizations. The patient should demonstrate a number of cognitive, social, emotional and motor developmental milestones. She should have developed the desired cognitive abilities, as evidenced by her ability to describe her thoughts, feelings, and experiences and appreciate those of others. Further, she should be independent in forming friends and seeks acceptance from others. Finally, she should be able to perform physical activities such as sports and coordinate body activities effectively.

Developmental Assessment of a Child Using a Developmental Theory (Piaget)

Piaget’s theory of development can be applied in the above case study. According to Piaget, child’s development occurs gradually in four stages. The stages include sensory motor (birth to 2 years), preoperational (1.5-7 years), concrete operational (7-11 years), and formal operational (12-19 years). Based on the above, the child in the case study is in the concrete operational stage in Piaget’s model. Children in this stage are expected to have developed logical thinking. They have operational thought process characterized by their ability to relate abstract concepts with their experiences (Chiocca, 2019). Children in this stage also have the ability to express their feelings, emotions, and experiences. They also acknowledge the feelings and emotions of others.

The focus of physical assessment when providing care to this client entails asking specific questions that they can answer to the best of their abilities and not her parents. The assessment should also focus on the exploration of issues relevant to the interests of the child. An example is asking questions related to the school, friends, her likes and dislikes. The nurse should provide information in simple language that is easy to understand for the children (Hockenberry et al., 2021). Since the visit by the client to the hospital was for regular assessment, it is anticipated that normal findings will be obtained.

NRS-434V Week 5 Benchmark: Individual Client Health History And Examination Conclusion

The physical assessment of pediatric patients utilizes different approaches. The assessment depends largely on the developmental stage of the children. Nurses should demonstrate adaptability by being able to change the physical assessment approaches to suit the age group of their patients. In addition, theories of development such as Piaget’s should be used to inform the assessment findings.

NRS-434V Week 5 Benchmark: Individual Client Health History And Examination References

Chiocca, E. M. (2019). Advanced Pediatric Assessment. New York, NY: Springer Publishing Company.

Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2021). Wong’s Essentials of Pediatric Nursing. Los Angeles, CA: Elsevier Health Sciences.

Tagher, G., & Knapp, L. (2019). Pediatric Nursing: A Case-Based Approach. Philadelphia, PA: Wolters Kluwer Health.   

Developmental Assessment and the School-Aged Child

School-aged children’s developmental assessment mainly entails the collection of information relating to the expected emotional, physical, and mental abilities of a child between the age of 5 and 12 years. The essential aspects of the collected information include learning approaches, socioemotional, physical/motor, language, and cognitive abilities among others (Scheuer et al., 2019). The main aim of this procedure is to gain a record of the child’s growth in all areas for early identification of developmental health complications to promote timely interventions. It is also necessary to identify and address the child’s special needs based on the assessment outcome. The purpose of this paper is to examine the developmental needs of school-aged children between the ages of 5 and 12 years and the application of developmental theories such as Erickson.

Comparison of Physical Assessment Among School-Aged Children

As our age advances, so is our needs, hence the difference in assessment data obtained at every age.How the data is collected is also different among children of different ages. For example, the developmental assessment of a child who is just joining school, like a 5-year-old, mainly involves the parent or guardian as the main historian, as they are unable to express themselves effectively, whereas the assessment of an older student, 12 years of age, will involve the child as the main historian given their coherent ability to express themselves. Clinicians normally decide on the assessment method by observing the child determine their ability to express themselves. Additional assessment tools include standardized tests, portfolios, care provider rating scales, and parent rating scales (Klingberg et al., 2019).

These assessment tools can however be modified to match the age of the child and their developmental stage(Erdei et al., 2020). For instance, a 5-year-old will require the questions on the standardized test to be read out loud and filled by the clinician. On the other hand, a 12-year-old will be given the chance to read and fill out the questionnaire by themselves.

Typical Assessment for a Child of a Specific Age

L.P is an 11-year-old white male who was born before the 37^th week with only 2.5kgs through the spontaneous vaginal delivery. The child stayed in the newborn unit for about 2 weeks following complications such as birth asphyxia (Erdei et al., 2020). The child however gained about 450g when he was leaving the ward. For the developmental assessment of L.P, it is necessary to identify the physical, emotional, social, and cognitive milestones appropriate for his age. Physically, he is expected to show signs of puberty, improved handwriting, and the need to eat and sleep more. Emotionally, L.P is expected to display key milestones such as starting to question authority figures, developing better decision-making skills, and beginning to resist physical affection from parents. Socially, he is expected to be able to form a complex and strong friendship and explore new hobbies. Lastly, the key cognitive milestones expected for the child include experiencing a great sense of responsibility and increased attention span among others.

Developmental Assessment of a Child Using a Developmental Theory (Erickson, Piaget, Kohlberg)

            The psychologist Erik Erikson classified the human developmental stages into 8 different categories. The patient described above appropriately fits in the 4^th stage which is named “Industry vs. Inferiority” for children between the ages of 5 and 12 years (Gross, 2020). The basic virtue crucial among children within this age group as described by Erikson is competency. As such, with the utilization of Erikson’s theory of development, the assessment of L.P should mainly focus on his reading and writing abilities. At this age, L.P is expected to display coherent cognitive skills improved through school experience. How he related with his peers is also vital at this age to promote his self-esteem.

The assessment process will thus involve the mother, teachers, and his best friend to provide additional information on how he relates with other people in different situations. At this point in the assessment process, the provider will discuss with the parent any complications or unusual events during pregnancy and explain whether their child’s developmental milestones are age-appropriate (Erdei et al., 2020). To gain cooperation from the child, it is necessary to conduct the assessment when he is together with his friends. Some children may display delays in their development like delays in reading or writing.

NRS-434V Week 5 Benchmark: Individual Client Health History And Examination Conclusion

The developmental assessment of school-aged children is vital in determining their welfare in school and at home. The assessment process utilizes age-appropriate tools to determine whether the child has grown appropriately emotionally, physically, and socially. Erikson’s theory of development which describes 8 different developmental stages is normally utilized to help with the assessment process for the identification of special needs among children that must be addressed.

NRS-434V Week 5 Benchmark: Individual Client Health History And Examination References

Erdei, C., Austin, N. C., Cherkerzian, S., Morris, A. R., & Woodward, L. J. (2020). Predicting school-aged cognitive impairment in children born very preterm. Pediatrics, 145(4). https://doi.org/10.1542/peds.2019-1982

Gross, Y. (2020). Erikson’s stages of psychosocial development. The Wile