Essential IX

E-folio Essential IX
Jennifer Burrier
Frostburg State University
RN-BSN Nursing Program

Essential IX

E-Folio Essential IX

Essential IX is necessary for the Bachelor of Nurses program to have students apply
generalist nursing practice. The class taught how to perform a comprehensive and focused
assessment on a subject. Human growth and developmental theories were taught in order to
determine the developmental stage. Culturally diverse care was also emphasized because it is
important to understand ones culture to properly care for the person. In taking these matters and
other aspects into account, NURS401 Health Assessment fulfilled the requirement for Essential
IX in the RN-BSN Nursing Program
Exemplar
The project chosen was assessment of a 40 year old male. Not only was it a physical
assessment, but it also took into account the spiritual, emotional, developmental and other
aspects of the subject, being a comprehensive assessment on the subject. The assessment used
many dynamics that were taught in the course such as if the subject was in a safe environment
and his developmental stage.
Reflection
This class expanded my knowledge about how to properly assess a patient. Assessing a
patient physically is very important, but it is also important to many aspects about the subject,
such as socioeconomics and social dynamics. For instance, a person might be stressed over
losing a job and bringing in income for his family so he might increase smoking cigarettes to
cope with his stress and it then affects his health by inhaling the toxins into his body. Essential

Essential IX

IV was invaluable to teach how to care for patients across their lifespan which is one of the goals
in The Essentials of Baccalaureate for Professional Nursing Practice.

References
American Association of Colleges of Nursing The Essentials of Baccalaureate for Professional
Nursing Practice. Washington DC, Author

Your Name:
Jennifer Burrier
Date:
5/10/13

Patients initials:
M.B.

Chief complaint/reason for seeking care:

Chronic headaches for the past few weeks.
History of present illness:
This 40 year old male has been complaining of recent headaches for the past few
weeks that have not resolved with over the counter medicines, which the patient
has relied on with success to alleve his headaches in the past. Patient states the
headaches often start in the afternoon and are in the back of his head. He states it

Essential IX
is a tightening sensation and a very dull but persistent headache. He rates the pain
up to a 7/10, when he takes the OTC meds that he normally takes his pain is
reduced to 5/10. Patient also states that he has had more back and neck discomfort
lately. The patient states he has had increased stress at work and has needed to
work on his computer in his office for up to 14 hours a day. The patient also states
that due to increasing work and stress he has not slept as much as he normally
does and also his diet has not been very balanced. Patient states his eyes have
been feeling more strained lately but denies having vision disturbances.
Past medical and surgical history:
Patient denies any surgical histories. He had anemia as a child that was treated
with iron supplements but denies having problems as an adult. Patient had a badly
sprained right arm when he was 10, but denies having broken bones in the past.
Patient suffers from seasonal allergies-pollens, but denies needing inhalers or
prescription medicines, just OTC medications. Again patient does have occasional
headaches usually can be alleviated with OTC meds. Patient wears glasses for mild
myopia, but does not wear them all the time.

Allergies:
Seasonal allergies to pollens, denies allergies to food or medications
Current medications (Rx & OTC):
Tylenol 650mg PO PRN- headaches and general pain, Ibuprofen 200-400mg PO PRNheadaches and general pain, multivitamins PO QDAY, benadryl 25 mg PO PRN for
seasonal allergies. Denies Rx meds
Family health history:
Patient has both parents that are living, maternal grandmother still living. Paternal
grandparents lived past their 80s. Maternal grandfather died at 62 from a heart
attack. Family history does not include cancer or stroke. Paternal grandfathers
side does have history of Parkinsons.
Social history:
Patient has Bachelors degree in Business, is currently employed at a bank working
in loan analysis, mostly office work. He has been at his current workplace for 14
years. Patient grew up with a brother with parents married. Patient denies
smoking, drug or alcohol use. Denies any domestic abuse presently or in the past.
Patient is married with two children 7 and 10 and lives with his wife. He is
heterosexual and believes in monogamy, has been married for 13 years. He

Essential IX
classifies his economic status as middle class.
Spiritual assessment:
Patient states that religion is important in his daily life. He goes to a Methodist
church, where he has gone during his whole life. Patient believes that prayer and
God are very important in daily life. The Bible is used as a daily guide, prayer is
very important and can assist in life but not necessarily cure since God has the final
decision and is in control. He does not smoke, drink or use drugs due to following
the Bible. He does not have diet limitations in his religion.
Cultural assessment:
Patient is Caucasian. He has lived in Frederick County all his life, in addition to his
parents and both sets of grandparents. He speaks English solely. He was raised in
a household where the male is the sole provider and makes the majority of
decisions, but he believes in equality in his marriage. Believes that marriage is
important before having children and that divorce is only when other options fail.
He trusts Western medicine, he is not comfortable with Eastern medicines since he
is not very familiar with them and often feels skeptical about them.
Nutritional assessment:
Patient drinks 2-3 cups of coffee per day but he states he has been drinking about 2
more cups additionally lately due to increased work. Patient usually eats three
meals a day with light snacks often in between. He eats fast food, including pizza
about 4 times per week. He eats with the family about 50-70% of the time. He
states that he should be eating more fruits and vegetables- he only has one to two
servings per day, but he states that he does not like the texture of them. He
states even as a young child he did not like the consistency of fruits and vegetables
and it was a chore for his parents to get him to eat his vegetables on his plate. He
does state that he takes multivitamins daily. He does not have monetary limitations
on buying a variety of foods.
Health maintenance:
Patient averages 7-8 hours of sleep per night, denies difficulty sleeping but states
lately he has been averaging 5-7 hours due to increased work load. Patient has
minimal exercise- he walks a few blocks from the parking deck to his work, but
states he recently bought a bike and plans to bicycle a few times per week. Patient
states he says he has a moderate stress level, but it has been increasing lately at
work. He tends to unwind by listening to music or watching television. Also he
enjoys spending time with his family.
Review of systems:

Essential IX
Patient states that he feels like he is in generally good health.
Denies itching, rashes or changes in skin integrity. Does state has many moles on
his body, but has not noticed a change in color, texture or size in them. States he
does have mild acne on his back and some dandruff on his scalp, this is normal for
him.
Denies blurred vision or vision changes. Does wear glasses of mild myopia. States
he does not wear them all the time and probably should wear them more when he
works at his computer. Feels like eyes have been strained and tired lately.
Denies difficulty hearing but states he often has excessive ear wax and needs to
clean them on a regular basis- uses OTC ear wax removal kits.
States he does have 2-3 colds a year, mostly in winter. Also has seasonal allergies
in the spring with nasal congestion and sneezing, symptoms relieved with OTC
allergy medicines.
Denies throat soreness, tenderness, dysphagia.
Denies dyspnea, coughing, or problems with breathing.
States he does have a mild heart murmur that has been known since he was a child.
Denies any other cardiac problems.
Denies nausea, vomiting. States he is not eating like he should lately- not balanced
meals. States his bowel movements are not as frequent- about every other day
instead of almost daily. No changes in stool color on consistency. States he may
have more flatulence and does have some mild indigestion at times, but does not
take OTC medications for it.
Denies changes in urination, no pain, frequency, urgency or color changes.
Does state he has had mild back pain and neck pain/stiffness. Has history of
sprained right arm as a child but denies problems with the arm.
Has history of occasional headaches that are allieved with OTC medications, but
states over the last few weeks his headaches have increased and OTC medications
have not taken away the pain. Denies memory loss, head injuries, or other
neurological deficits.
States he has increased stress due to increased workload at his job. States his
concentration has mildly decreased since he feels overwhelmed. Does feel like he
has increased tension and does feel more on edge. Denies sleeping difficulty but
admits he has not been getting his normal amount of sleep per night- 5-7 hours
instead of 7-8 hours.
Admits to decreased libido due to feeling more stressed and tired lately. Denies
having difficulties in erections or impotence.
States he has been drinking more coffee lately, has not eaten regular meals lately
and not as well balanced. Feels like he has been eating on the run lately. Says he
may have gained a few pound lately, pants feel slightly more snug.
Denies excessive sweating, heat/cold intolerances. Does state he does feel more
feel more tired lately due to stress and not sleeping as much lately.
Denies lymph node tenderness.
Denies noticing an increase in bruising or bleeding.

Physical examination:
VITALS: Blood Pressure of 142/95, apical pulse of 75. Respirations at 18. Oral

Essential IX
temperature is 98.4. Pulse ox is 98% on room air. Pt is 5'11" and his weight is 180.
He denies having a headache at the time of assessment.
CONSTITUTION: Patient appears to be well nourished with a clean well dressed
appearance, demonstrates good hygiene. He has a straight posture and equal gait,
he does not use assistive devices for walking. He is articulate with his speech and
answers appropriately showing a concrete thought process. He does seem slightly
rushed, looking at his watch frequently as if he is in a hurry. He is slightly anxious
and answers questions quickly. When asked if he needed to be somewhere, he
states he has a deadline to complete at work by the end of the day. He denies
having domestic problems, but states he feels guilty not spending time with his
family lately due to increased work.
HEENT: Pt is not wearing his glasses at time of assessment, says he is having
trouble viewing the 6th line on the Snellen Chart- some letters are a little blurry. He
has extreme difficulty reading the 7th line. Pt states it has been about three years
since his last eye examination. Eyes show Cardinal Fields of Gaze smoothly and
symmetrically. Pupils are equal and reactive to light, corneas are clear and sclera is
white, but does show a light pink tinge due to excessive vessels. Patient states his
eyes are "bloodshot". The lacrimal glands have minimal exudate and do not show
signs of inflammation of conjunctivitis. Pt is able to hear whispering 2 feet away
from each ear and can restate the phrase appropriately. The ear canal is light pink
but does show a fair amount of yellow cerumen. Tympanic membrane is pearly gray
with defined landmarks and shows a cone light reflex. The mouth has slightly dry
cracking lips, breath does not have foul odor. Gums and mucosa is light pink and
shows adequate hydration. The nose shows patent nares without drainage, the
mucosa is pink without swelling. The septum is at midline without deviation.
RESPIRATORY: Patient shows no indication of labored breathing. AP diameter is 1:2.
The chest wall is symmetrical and accessory muscles are not noticed when patient
breathes. Respirations are even and controlled. Coughing was not heard when
assessed. The thorax did not show any abnormalities upon palpation and no
tenderness was noted. DIaphragmatic excursion was shown to be at 3.5 cm. Lobes
of lungs were auscultated for inspiration and expiration and adequate air sounds
were heard.
CARDIOVASCULAR: Regular heart rate and rhythm were heard. S1 and S2 were
ascultated. No gallop, murmur or rub heard. Extremity pulses were palpated and
equal comparing the extremities. Skin warm to touch, not moist or clammy. No
edema in extremities. JVP reading was 3cm. Capillary refill was >3 seconds. No
clubbing was found in fingernail beds. There was hair on extremities and no ulcers
were noted.
GASTROINTESTINAL: PT does not have abnormal bulges in abdomen when viewed.
There is symmetry between the two sides of the abdomen. Upon auscultation all 4
quadrants had active bowel sounds. Patient denied tenderness when abdomen was
palpated. Patient states his latest bowel movement was yesterday, stool was dark
brown and slightly hard, had been three days before the previous bowel movement.
GENITOURINARY: Patient does not have tenderness at bladder. His urine is clear
light yellow and not malodorous. He denies having burning, itching, hesitancy or

Essential IX
frequency. He states he urinates every 3-4 hours on average.
INTEGUMENTARY: Patient does not have any wounds on his body, skin is intact. A
few small bruises on his arms, but no excessive bruising.

Nursing diagnoses, patient goals, interventions:

Patient states he does want to improve his dietary intake with better food choices,
decreasing his sugar, simple carbohydrate and fat intake. He also states he does
not exercise on a regular basis and wants to increase his exercising. Patient also
mentioned about being stressed at work and will try methods of relaxing, such as
exercising, breathing techniques and stretching, especially when tense at work.
Patient also will try to increase his sleeping time.