Physical Assessment

Physical assessment is one of the process to assess and obtaining information about a patient’s health history and family medical history which can help in planning a patient’s care. A nurse uses subjective and objective data gathered to assess patient and the five nursing process to conduct patient’s health care. Interviewing patients is the first step. This paper discusses the health history of a lady I interviewed known as Mrs. E, family medical history, and overall reflection of the interview.
Health History
. I have an opportunity to interview Mr. J. He is a white man, resides in Chicago, Illinois. Mr. J is 35 years old. He is not married, but in a serious relationship with a lady who he intends to marry. .Mr. J is
J stated he takes cereal with fruits, nuts, milk and a cup of green tea for breakfast, lunch pasta or brown rice with chicken or fish and potato, roasted chicken with salad for dinner. He takes alcohol occasional, drink one cup of coffee every day and a lot of water. Also, He does not use illicit drugs or abuse any drugs. He goes to the gym and exercise every day at least for one hour, he likes to do push- up and press up and weight lifting to build muscles. He needs no assistance with activities of daily living. Mr. J stated no domestic violence in his home; he has a good relationship with his girlfriend. They respect and care about each. He takes care of his family, but always makes out time to meditate and reflect on certain things in his life. He travels a lot. Mr. J uses a seat belt, while driving, smoke alarm at home and changes the battery every year. As a businessman he hardly uses gloves, but he practice proper hand hygiene. In addition, sleep about 4 to 5 hours some days while sometimes, he gets an enough sleep. He hardly takes naps because he is busy with work. Mr. J has no mental problem; his social, self-concept, and spiritually well-being are
J and gathered the subjective data. I did a head to toe assessment on him. Patient was alert and oriented times five. Patient knows his name, date of birth, where he was, date and time. Patient was cooperative and follows direction. I inspected his head looks symmetry, no bruises or discoloration, hair is equal distributed, and I palpated his head, no lump and patient stated “he does not feel any pain or tenderness”. I examined his ears, no lesion, bruises or rashes. Then, inspect the ear canal, no discharge, foreign bodies or presence of cerumen. I Palpated the auricles has firm cartilage and no pain or tenderness. Cranial nerve VIII, I did a whispering test, patient was able to repeat what I whispered to his ears. Inspections of eyes, patient’s eyes are symmetry, no swelling on lachrymal sac, redness and equal hair distribution on the eyebrows. Test for cardinal gaze, patient was able to follow direction and without moving his head or jerky movement of the eyes (nystagmus). Cranial nerve II, I tested for pupillary reaction to light; patient’s eyes react to light or constricted. Also, I inspected the anterior and inferior surface of the nose, no bruises or lesion, same color with the skin,