Physical Assessment Research Paper

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Physical assessment is one of the process of assess and obtaining information about patient’s health history and family medical history which help in planning patient’s care. A nurse uses subjective and objective data to assess patient and the five nursing process to conduct patient’s health care. Interviewing patients is one first step. This paper discusses the health history of Mrs., family medical history, and overall reflection of the interview. I have an opportunity to interview Mrs. E. She is an African American woman resides in Tinley Park, Illinois. Mrs. E is 39 years old, married with two boys’ age 2 years and 9 months old. Mrs. E is 5’4, weighs 133 pounds and BMI 22.8. She is a Christian and practice Christian religion …show more content…
said “she is eating to maintain her weight. Eat oatmeal or cereal for breakfast with milk and fruits, small rice with chicken for lunch and vegetable soup made with spinach and okra for dinner. She does not take alcohol, but drink two cups of coffee as needed and a lot of water. Also, she does not use illicit drugs or abuse any drugs. She engages in physical activity 20 -30 minutes of walk three times a week and no assistance with activities of daily living. Mrs E. stated no domestic violence in her home, her husband is a good man and treats her with respect and take care of her and kids. She takes care of her family, but always makes out time to mediate and reflect on certain things in her life. She spends quality time with her family and takes vacation with them. Mrs. E uses seat belt while driving, smoke alarm at home and changes the battery every year. As a medical assistant she wears gloves with each patient and practice hand hygiene. In addition, sleep about 6 to 7 hours every night; hardly take nap because she has a toddler and 9 months old baby. Mrs. E has no mental problem; her social, self-concept and spiritually are well …show more content…
She is healthy and fit”. Patient said no fever, malaise, chills and night sweat. Also, no skin problems, she washes her hair with shampoo and bath at least two times a day, dry and put lotion on skin. She said no skin loss, change in texture and change in nails. Her sun exposure varies, uses sun screen, wear cover cloths and hat to protect her body from sun. She does not have any head injury, frequent headaches, and dizziness. She does not have any eye problem, went for eye or vision check five years ago. She has no ear infections, earaches, hearing loss and does not use hearing aids. She use clean cotton balls around the ears and never use inside the ear. Patient does not have any nose problems and have not notice any change in smell. She is not suffering from any throat infections or bleeding gums. She brush teeth twice daily and visit dentist every six months, floss and giggle with mouth wash. She does not have any neck pain or problem with movement. Patient does not have any pain, and lumps in breast or in axillary areas. She examines her breast by palpating with finger around the breast and did mammogram March 2016. She does not have any respiratory problems, breath fine, and no shortness of breath or weakness. Also, she has no chest pain and no swelling of legs or discoloration of hands or feet and no pain when walking. Patient does not have heart burn, constipation; bowel

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