To complete a holistic/variable assessment, utilize the same person that you obtain a health history from to perform an assessment of variables.

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Holistic Assessment/Variable Paper

To complete a holistic/variable assessment, utilize the same person that you obtain a health history from to perform an assessment of variables. Assessment of the variables provides a holistic view of the client and which attribute to their overall health. The variables assessed are to be as follows:

• Developmental – includes physical and cognitive development. Document stage of development that your patient is currently experiencing (i.e. integrity vs. despair); describe the stage of development that your patient is in and why this whole development stage is important to nursing care. References two peer reviewed articles on development.

• Sociocultural – includes your patient’s culture. What values, heritage, and culture he or she is practicing or adhering to from their culture. How does your patient socialize? i.e, having family visits every week, month etc., what culture environment does your patient reside in, Chinatown etc. Explain why the patient’s sociocultural background is important to the nurse in relationship to delivering nursing care. Chapter 2 – Jarvis textbook . References two peer reviewed articles on Sociocultural impact on delivery of care.  
• Spirituality – includes your patient’s religion, religious background, and spiritual well-being. Explain why the nurse needs to know this information in order to provide nursing care. Chapter 2 – Jarvis textbook. includes your patient’s religion, religious background, and spiritual well-being. Explain why the nurse needs to know this information in order to provide nursing care. Chapter 2 – Jarvis textbook. References two peer reviewed articles on Spirituality effects on patient physiologic well-being. 

• Psychological – includes your patient’s orientation, mood and affect, ability to respond and carry on a conversation with you. Explain why the nurse needs to know this information in order to provide nursing care. Chapter 5 – Jarvis textbook . References two peer-reviewed articles on the effect of psychological health on physiologic well-being.  The paper should be in APA format 6th edition. Therefore, it is highly recommended that you purchase this book in order to complete this assignment. Please proof read your paper prior to submission to ensure you have completed a spell check, grammar check and the paper is in the correct format, this section counts for 10% of your paper. Visit PurdueOWL or APAstyle.org for assistance

Holistic Assessment/Variable Paper: Due on November 13, 2015

To complete a holistic/variable assessment, utilize the same person that you obtain a health history from to perform an assessment of variables. Assessment of the variables provides a holistic view of the client and which attribute to their overall health. The variables assessed are to be as follows:

· Developmental – includes physical and cognitive development. Document stage of development that your patient is currently experiencing (i.e. integrity vs. despair); describe the stage of development that your patient is in and why this whole development stage is important to nursing care. References two peer reviewed articles on development.

· Sociocultural – includes your patient’s culture. What values, heritage, and culture he or she is practicing or adhering to from their culture. How does your patient socialize? i.e, having family visits every week, month etc., what culture environment does your patient reside in, Chinatown etc. Explain why the patient’s sociocultural background is important to the nurse in relationship to delivering nursing care. Chapter 2 – Jarvis textbook . References two peer reviewed articles on Sociocultural impact on delivery of care.

· Spirituality – includes your patient’s religion, religious background, and spiritual well-being. Explain why the nurse needs to know this information in order to provide nursing care. Chapter 2 – Jarvis textbook. includes your patient’s religion, religious background, and spiritual well-being. Explain why the nurse needs to know this information in order to provide nursing care. Chapter 2 – Jarvis textbook. References two peer reviewed articles on Spirituality effects on patient physiologic well-being.

· Psychological – includes your patient’s orientation, mood and affect, ability to respond and carry on a conversation with you. Explain why the nurse needs to know this information in order to provide nursing care. Chapter 5 – Jarvis textbook . References two peer-reviewed articles on the effect of psychological health on physiologic well-being.

The paper should be in APA format 6th edition. Therefore, it is highly recommended that you purchase this book in order to complete this assignment. Please proof read your paper prior to submission to ensure you have completed a spell check, grammar check and the paper is in the correct format, this section counts for 10% of your paper. Visit PurdueOWL or APAstyle.org for assistance

You MUST HAVE ATTESTATION from the writing center that your work was reviewed by them. You need to schedule an appointment with the writing center by emailing Kelley Coleman at kcoleman@global.edu or by telephone at 703-212-7410 x 5241.

Assignments shall only be submitted electronically via SonisWeb at 5:00 pm. Assignments turned in beyond this specified time will earn “Zero.” Students found to have committed acts of academic dishonesty such as plagiarism will also receive zero.

Holistic Assessment/Variable Paper Grading Rubric

Beginning	Developing	Exemplary
Developmental Assessment (20%):	Missed two or more of the components stated to receive exemplary. 5 points	Missed one of the component stated to receive exemplary. 10 points	· Discusses physical and cognitive development. · Documents stage of development that your patient is currently experiencing · Describes the stage of development that your patient is in and why this whole development stage is important to nursing care. · References two peer reviewed articles on development. 20 points
Points
Beginning	Developing	Exemplary
Sociocultural Assessment (20%)	Missed two or more of the components stated to receive exemplary. 5 points	Missed one of the component stated to receive exemplary. 10 point	· Includes your patient’s culture. What values, heritage, and culture he or she is practicing or adhering to from their culture. · Include how your patient socializes. · Explains why the patient’s sociocultural background is important to the nurse in relationship to delivering nursing care. · References two peer reviewed articles on Sociocultural impact on delivery of care. 20 points
Points
Beginning	Developing	Exemplary
Spirituality Assessment (20%):	Missed two or more of the components stated to receive exemplary 0 points	Missed one of the component stated to receive exemplary. 10 points	· Includes your patient’s religion, religious background, and spiritual well-being. · Explain why the nurse needs to know this information in order to provide nursing care. · References two peer reviewed articles on Spirituality effects on patient physiologic well-being. 20 points
Points
Beginning	Developing	Exemplary
Psychological Assessment (20%)	No functional assessment was completed 0 points	Missed one of the component stated to receive exemplary. 10 points	· Includes patient’s orientation, mood and affect, ability to respond and carry on a conversation with you. · Explains why the nurse needs to know this information in order to provide nursing care. · References two peer-reviewed articles on the effect of psychological health on physiologic well-being. 20 points
Points
Beginning	Developing	Accomplished	Exemplary
Grammar, APA format and references (10%)	Grammatical errors present consistently throughout the paper. AND Incorrect formatting and referencing zero	Grammatical errors present for the most part of the paper. AND moderate errors in formatting and referencing 5points	Grammatical errors present in less than a half of the paper. AND moderate errors in formatting and referencing 7 point	Minimal or no grammatical error present throughout the paper. AND no errors in formatting and referencing 10 point
Points
Beginning	Developing	Accomplished	Exemplary
Attestation (10%)	An attestation was not attached or student lied about seeking help from the writing center. Zero	Attestation is present and help is verified. 10 points
Points
Beginning	Developing	Accomplished	Exemplary
Total Points
Final Grade Comments

1

Health History

2

Health History

Health History

Name

Global Health College

Health Assessment

10/16/2015

Date __10/5/2015___

Examiner M. A.

1. Biographical Data

Initials __AM__ Phone __3017934596____

Address ___7001 96 Avenue, Lanham MD 20706

Birth date 07/28/1980 Birthplace Limbe, Cameroon___

Age __35__ Gender __Female__ Marital Status _Married__ Occupation _Nurse__

Race/ethnic origin __Black/Cameroon__ Employer __Karen For Kids Inc.__

2. Source and Reliability: The source of information is reliable because it is provided by the patient herself.

3. Reason for Seeking Care: Patient is seeking help because she has been having persistent diarrhea and abdominal cramps for two days.

4. Present Health or Health of Present Illness: Diarrhea and abdominal cramps.

Patient AM, came to the hospital at 4pm on 10/5/2015, complaining of persistent diarrhea and generalized abdominal cramps. She states that her illness started after she came back from a family swimming picnic on 10/2/2015 at 7pm. She states that her illness started with generalized abdominal cramping that was followed with her passing watery non-tarry stool with no foul smell. She says she has been having 5 episodes of diarrhea each day for two days. Patient also states that her illness is triggered when she eats any food or when she wants to do her daily exercise. Patient states she feels a little weak. Patient added that she has also taken Over The Counter (OTC) Imodium 4mg twice a day for two days but doesn’t feel any better. That is why she came to the hospital today for help.

5. Past Health

Ms AM says she has been healthy over the past years, except for today when she complains of diarrhea and abdominal cramps. She denies having any past history of childhood illnesses: measles, chicken pox, mumps, meningitis, impetigo. Patient confirms haven had pink eye at age 10years old, which was treated with some home remedies (soaked clean compress and OTC eye drop called artificial tears). Patient says she had a minor nose injury at age 12 years that was treated by her pediatrician with pain medication. Patient denies having history of any chronic illness: diabetes, hypertension, asthma, cancer, Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), or stroke.

Patient denies haven been hospitalized before except during delivery. She also denies having any surgical procedures. Patient states that she has been pregnant three times, and she has three babies, two boys and one girl. She went ahead to say she had no premature procedures, delivery, abortion, or miscarriage. She added that all of her babies were carried full term and delivered after 9 months. of pregnancy. She labored for 4 hours for her first baby who was a boy, and 3 hours each for both second and third babies, a boy and a girl consecutively. She said her first baby weighed 7lbs and the other two weighed 8lbs each. All her three babies were delivered vaginally with no complications.

Patient states she is up to date with all her immunization, such as; influenza, pneumococcal, hepatitis “A and B”, varicella, and DT aP vaccines. She also states that her last examination was when she went for her yearly physical exam on August 15th 2015 where she did her complete blood work, EKG, chest x-ray, pap smear, and all her results were normal.

She denies having any drug or food allergy, and her body has never reacted to any food, medication, or herbs. She has been taking 4mg Imodium twice a day for the past two days for her diarrhea.

6. Family History – Specify

When interviewed, patient denies having any family history of: heart disease, high blood pressure, stroke, diabetes, blood disorders. She also denies having a family history of sickle cell, arthritis, obesity, asthma. She denies family history of any allergies: drugs, food, herbs. She continues that her family has no history of suicide, kidney disease, tuberculosis, or seizures. However, patient confirms that her family has a history of breast cancer. She says her mother was diagnosed with breast cancer six years ago and was treated with a series of chemotherapy. She added that her mother is a breast cancer survivor today.

Genogram

Mother: 62 years old History of breast cancer. Diagnosed with breast cancer six years ago. Father: 65 years old No history of illness or chronic disease.

Sister : 33 years old No history of illness or chronic disease. Patient: 35 years old Presently complains of d iarrhea and abdominal cramps . Brother : 38 years old No history of illness or chronic disease. Sister: 40 years old No history of illness or chronic disease.

7. Review of Systems

Patient says she weighs 165 pounds. She added that she has not experienced any abnormal weight gain or weight loss. She says she works on her weight by exercising almost every day. Patient denies: fever, chills, sweat, or night sweat, but she says she feels a little weak secondary to the persistent diarrhea and abdominal cramps for two days.

Patient denies having eczema, change in skin color, rash or lesion, mole, itching (pruritus), bruising, hives, but she confirms having a history of dry skin in 2007, that was treated with an extensive prescription body moisturizing cream (Eucerine)which she still uses up to date.

Patient denies any type of hair loss, for example; patchy, idiopathic, non-cicatrical hair loss and she accepts change in her thin hair texture which was caused by her excessive use of multiple hair relaxers in 2009. This was treated when she stopped putted hair relaxers in her hair.

Patient refused a history of brittle or splitting nail, jagged or late clubbing nails, and she says she doesn’t use nail polish because of her occupation. She denies exposing herself under the sun, and says she takes good care of her skin and makes sure to deep condition her hair weekly.

Patient denies history of unusual headache, head injury, dizziness, vertigo, or history of head surgery. When patient is asked about her eyes’ condition,

She denied having pain in her eyes, no redness or itchy eyes, no history of cataract or conjunctivitis, and no history of short sighted or long sightedness. She doesn’t use glasses, and says she always has yearly eye check –ups. In addition, patient refuses having a history of ear pain, no ear discharge, or reddish-blue discoloration, no history of tinnitus, or vertigo. She says she uses a safe self-cleaning method to clean her ears. She says she puts a few drops of mineral oil or water to soften ear wax. This allows wax to come out easily.

Patient refuses having any history of nose discharge, sinus problem, obstruction, epistaxis or allergy. She also denies having frequent cold or change in smell, but she confirms having a minor nose injury at age 12 years that was treated by her pediatrician with pain medication. Moreover, patient denies any history of sore throat or lesion, sore throat, bleeding gum, tooth ache, hoarseness or voice change, dysphasia, and altered taste. She also denies smoking and alcohol consumption. She denies having lost any teeth or use of dentures and brushes her teeth after every meal. She says she is up to date with her dental follow-up appointments.

Patient denies neck pain. There is no history of lump or swelling of the neck and no history of neck surgery or difficulty turning the neck to both sides (ROM). No history of goiter or lymph nodes.

When asked about her breasts, patient gives the following information: denies pain in the breast, nipple discharge, lump or thickness, rash, or swelling. She denies having any history of breast disease or breast surgery. Patient states that she does her breast self-examination monthly and does her mammogram yearly. She just did one during her general physical exam on August 15 2015 which came back normal. She says her mother was diagnosed with breast cancer six years ago and was treated with a series of chemotherapy.

Patient gives the following information about her respiratory system when interviewed. She denies having any history of chest pain or breathing difficulties, any history of respiratory (lung) diseases or any form of COPD: Asthma, emphysema, and bronchitis. She denies having any history of pneumonia, tuberculosis, or pulmonary edema. She also denies having any form of shortness of breath, wheezing or noisy breathing, and cough. She also denies exposure to pollution toxins. She refused smoking, and she says she works in a smoke free environment. She says she had a TB skin test last year that was positive and she was asked to do a chest x-ray that came out normal.

Furthermore, patient denies chest pain, dypsnea cyanosis, cough, fatigue, edema, or orthopnea, when she is asked about her cardiovascular system. She denies any history of heart diseases such as hypertension, heart murmur, anemia, coronary artery diseases (CAD), and she says she just did her last ECG, which was done on 15th August 2015 during her physical. Her PTA result was normal. In addition, patient denies leg pain, skin changes, coldness, numbness, or tingling of the extremities when she was asked about her peripheral vascular system. She denies swelling or enlargement of the lymph nodes. Patient also denies presence of any peripheral vascular diseases: thrombophlebitis, ulcers, and varicose veins. Patient states that her nature of job permits her to sit and stands on intervals, and she always has professional therapeutic shoes on.

On the gastrointestinal system patient gives the following information when interviewed. She states that her appetite is good with no recent changes, no food intolerance, no dysphasia, heart burn, nausea, or vomiting. She denies having history of gallbladder, jaundice, appendicitis, or colitis. Patient denies any abdominal surgery, but she states that she has been having diarrhea and abdominal cramping for two days after she returned from a beach picnic. She states consistently has six to seven watery non-tarry stool for two days, accompanied with abdominal cramping and weakness. She says she has take some over the counter (OTC) Imodium for diarrhea for two days which didn’t help and that her reason for consulting.

Patient states that she has no problem with her urinary system. She denies pain in the flank, groin, suprapubic region or lower back. She also denies having history of UTI, kidney stone, or kidney diseases. She stated that she never had a history of dysuria, polyuria, oliguria, or staining narrow stream urine. Patient states she always makes sure she does good douching and uses clean bathrooms and bath tubs to avoid UTI and doesn’t withhold urine voluntarily. She also uses kegal exercises after birth.

Patient gives the following information about her genital system. She states that she started menstruating (menarche) at age 13years, and she has a 28 days menstrual cycle that lasts for 4 days with moderate flow and no pain or abdominal cramping (dysmenorrhea). She also states that her last menstrual period (LMP) was on the 28th of September 2015. Patient denies vaginal itching or irritation, vaginal discharge, foul vaginal smell, vaginal sore or lesion. She also denies pelvic surgery, and she states that her last pap smear exam was done on August 15th 2015 during her annual physical exam and the result was good. Patient added the following information about her sexual health. She states that she is married, sexually active, and has intercourse only with her husband. She denies pain during sexual intercourse (dyspareumia), denies history of any sexually transmitted diseases (STDs) like gonorrhea, syphilis, herpes, and HIV/AIDS. She denies using any contraceptives.

As far as the musculoskeletal and neurological systems are concerned, patient gives the following information. She denies any joint pain, stiffness, or limitation on any joint. She denies muscle pain or weakness. Patient states that she has no history of bone trauma or deformity, arthritis, or gout. Patient states that she is able to manage all her daily activities which include cooking, house cleaning, grooming self, dressing, ROM with no physical limitations. Patient also denies using any walking aids. When asked about her neurological system, patient denies any unusual frequent severe headaches, dizziness, head trauma, weakness, numbness, tingling or difficulty swallowing or speaking, and loss of sensory stimuli. Patient also denies having any illness related to neurologic system such as seizures, stroke, black out, fainting, mood change illness(depression), or mental health illnesses (hallucination).

Moreover, patient denies having history of any hematologic abnormalities. She denies anemia, bleeding disorder such as hemophilia, blood clots, lymphoma, and myeloma. Patient also denies exposure to toxic agents, and radiation. She also denies history blood transfusion. Patient also denies any changes in her endocrine system. She denies changes in skin pigmentation or texture, intolerance to heat or cold, excessive urination, hunger, thirst, or being sweaty (diabetic symptom). She denies endocrine disorder diseases: Hyperthyroidism symptoms (hand tremor, weight loss fatigue, or muscle weakness), Addison diseases, or hypothyroidism.

Functional Assessment (Including Activities of Daily Living)

Patient states that she attended University of Yaoundé in Cameroon, where she graduated with a 1st degree in history. She also says she attended the University of District of Columbia where she graduated as a License Practical Nurse (LPN) . She is presently a full time RN student. Patient stated she has worked as a home health aide and a GN, and she is currently working as a fulltime LPN in a nursing home. She adds that she is financially sufficient with the help of her husband. She says her family lives a moderate healthy lifestyle. She also continues that she believes in God and this provides her strength, and she is a Roman Catholic Christian. Patient stated that she is up to date with her doctor’s appointments, enjoys exercising, eats healthy, and also has interest in learning.

Patient gives a rundown of her typical day off work as follows: she wakes up at 8am, takes a shower and goes to school. She takes a two hours nap after school. At 4 pm, she goes to the gym for an hour and at 6 pm, they all eat dinner (husband and kids) , then she studies for 4 hours and goes to bed at 11pm. Patient also states that her husband helps with most of the household chores. She also confirms that she does not need help with her activities of daily living, for example; feeding, bathing, grooming, etc.

Patient says she enjoys music, dancing, exercising, movies, and reading during her leisure time. Patient states that her exercise pattern consists of bike spinning 3 times a week with 30 minutes of treadmill warm up. She burns out about 500 calories per session of exercise which her body tolerates very well.She says that she takes at least 2 hours of nap time and 5hours of sleep every night without sleeping aids.

Patient states that she eats a balanced diet, but tries to reduce the amount of fat and carbohydrates intake. She says for breakfast, she has cereal or oatmeal with skim milk, a cup of juice or fruit, with a cup of coffee. For lunch, she has a ham or chicken sandwich and drinks a lot of water. For dinner, the family eats together food rich in vegetable and fiber. She has no food intolerance and she is responsible for providing the household with food.

Patient states that she was brought up by her religious and God-fearing parents. She experienced a quiet family life with her mom, dad, and 2 siblings. She states that she gets acquainted to people easily and she is very outgoing and can deal with any personality. She has a good marital relationship with her husband, as well as a good relationship with her friends and coworkers. She avoids people who want to influence her negatively. She also states that she has a strong support system; her husband, friends and family, coworkers, and classmates are always there for her when she needs help. She says she spends 5 hours a day to nap or study in a quiet place. Patient confirms that she is stressed with school assignments and becomes anxious during exams. In order to cope with this she uses the following methods to relieve her stress: relaxation, positive thinking, healthy eating, and regular exercise. She thinks these methods work for her.

She doesn’t smoke, doesn’t drink alcohol, denies using drugs such as marijuana, crack cocaine, heroin, or barbiturates. She added that she lives in a single family home with adequate heat and utilities with her husband and 3 kids. She states it is a drug free, environmental hazard and chemical pollution free zone. Patient denies any environmental hazards and says she uses safety measures when in a car by putting on her seat belt and also has easy access to transportation. She says she and her husband each own a car and also have bus stops in their neighborhood. Patient accepts residing in Cameroon but denies ever being in the military.

Patient says she has a lovely and safe married life with no incidents of abuse from her husband. She denies physical or sexual abuse from her husband and says her husband is her best friend. She says she is an LPN nurse, working in a nursing home. She denies working with hazardous chemicals. She adds that she enjoys helping patients but she gets emotional when patients are suffering and are in their dying stage.

Patient states:“Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity”. Again, patient says she is very persistent about having her breast exams because her mom is a survivor of breast cancer. She also says given her healthy lifestyle, she doubts she’d have chronic illnesses. She concludes that she expects nurses and physicians to promote healthy lifestyles and focus on disease prevention rather than treatment.

Reference

· Physical examination and health assessment by Javis

· How to clean out your earsproperly/upmc healthbeat

http://www.bing.com/search?q=share.upmc.com&form=IE10TR&src=IE10TR&pc=CPNTDFJS

· How do you define health www.who.int/definition

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