Health history assignment

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 Chronic Pain related to unknown etiology as evidenced by self-reports of pain “I feel pain when sitting or lying down mostly at night” using a standardized pain scale, 4/10 on a 0 to 10 numeric rating scale. The patient reports an altered sleep-wake cycle. 

GNRS 578
Health Assessment Lab
Week 10

Health History Assignment

Health History Assignment

Week 10 – Q&A for Part 2 & NANDA. Review APA format.

The APU Writing Center is a terrific resource for help with writing and formatting.

The Writing Center exists to support students, faculty,

and staff across APU’s campuses, including regional

locations. They provide free one-on-one, group, and/or

remote tutoring services.

Week 11 – Part 2 due Mon, Nov 7.

Almost done with this assignment! 

Another sample NANDA



APA Format
Title Page
APA Manual 2.3
(deductions if not met) Title of paper – title case, bold, centered, in upper half of page.
An additional double-spaced blank line appears between the title and the byline.
Includes: affiliation, course number & name, instructor name, assignment due date.
Page number in top right corner. 
2 Includes an introduction that frames the purpose and application/uses of a health history.
This is not an introduction to your patient.
Please refer to the beginning of chapter 4 in Jarvis for guidance.  
Problem Lists
2 Restates the problem lists from Part 1.
Please make changes to your lists based on feedback for Part 1.
Two lists show problems as actual problems or potential/risk problems (includes health promotions concerns).
Problems are listed in priority order.
Patient Perspective 6 Addresses:
what it’s like to have this problem according to the patient
the impact on his/her life
what they believe to be the cause of the problem
suffering experienced by the patient; includes description of patient’s fears and concerns
any signs of spiritual distress  

Health History Assignment RUBRIC for PART 2

Significant Concern Areas 12 Based on the information collected, includes personal and family history information.
Citations are included to provide evidence/source to support discussions. 
Evaluation of Nutritional Data
6 Identifies areas of strength and deficiencies, including an assessment of patient’s intake of salty and fatty foods.
Gives suggestions for improved nutritional well-being, including a plan to incorporate the changes needed based on the lifestyle of the person, income, job schedule, personal and cultural preferences, exercise, and sleep patterns.
Nursing Diagnosis 14 Applies nursing process to one priority problem identified.
Problem is within a nurse’s scope of practice.
Diagnosis is selected from NANDA (North American Nursing Diagnosis Association) Nursing Diagnosis Handbook, Ackley.
Diagnosis is formulated correctly with “related to” and “as evidenced by”. Goal is specific, measurable, appropriate, reasonable, with a time frame (SMART).
Includes two patient-specific nursing interventions that will accomplish the goal.
Rationale with a reference is given for each intervention. Provide an in-text citation.
Evaluation (or how evaluation would be done) is included.
APA Format
(deductions if not met)
Presents as an academic paper in narrative form.
Follows 7th ed. APA format, including page numbers, content format (margins, spacing, indentation, headings, section labels, and other), in-text citations and reference page.
Provides a minimum of 3 references. One point deduction for less than 3.
Check all punctuation in citations and reference list.
Grammar, Spelling and Punctuation
(deductions) Maximum 10% deduction for errors.
Organization and Flow
(deductions) Maximum 10% deduction for significant problems.
Submitted on Time 
(deductions) Please submit assignment to Canvas. Lecture Site
10% deduction in total grade for each day late.
42 Please see graded assignment in Canvas to view earned points along with instructor comments and annotations.
When viewing assignment grading, look at comments in the rubric and feedback in the document.


APA Format (7th ed.)

Chapter 2 – Paper Elements and Format

Title Page (2.3) / Fig 2.2 for sample

– title of paper – title case, bold, centered, in upper half of page

An additional double-spaced blank line appears between the title and the byline.

– affiliation, course number & name, instructor name, assignment due date

– page number in top right corner

Running head (2.8) only if instructor requests (not needed for HH Paper)

Text/Body (2.11)

On the first line of the first page of the text, write the title of the paper in title case, bold, and centered.

The text should be left aligned, double-space the entire paper (2.21 Line Spacing) with the first line of each paragraph indented.

Do not start a new page or add extra line breaks when a new heading occurs; each section of the text should follow the next without a break.

Heading Levels (2.27)

Formatting a Reference List

Each source you cite in the paper must appear in your reference list; likewise, each entry in the reference list must be cited in your text.

Your references should begin on a new page separate from the text of the essay; label this page “References” in bold, centered at the top of the page (do NOT underline or use quotation marks for the title).

All text should be double-spaced, including between and within references.

First line of each entry should be flush left with subsequent lines indented.


Reference List (2.12)

Reference List – Basic Rules for Most Sources

All lines after the first line of each entry in your reference list should be indented one-half inch from the left margin.

All authors’ names should be inverted (i.e., last names should be provided first).

Authors’ first and middle names should be written as initials.

For example, the reference entry for a source written by Jane Marie Smith would begin with “Smith, J. M.“

If a middle name isn’t available, just initialize the author’s first name: “Smith, J.“

Give the last name and first/middle initials for all authors of a particular work up to and including 20 authors. (This is a new rule, as APA 6th ed. only required the first six authors). Separate each author’s initials from the next author in the list with a comma. Use an ampersand (&) before the last author’s name. If there are 21 or more authors, use an ellipsis (but no ampersand) after the 19th author, and then add the final author’s name.

Reference List – Basic Rules for Most Sources (cont’)

Reference list entries should be alphabetized by the last name of the first author of each work.

For multiple articles by the same author, or authors listed in the same order, list the entries in chronological order, from earliest to most recent.

When referring to the titles of books, chapters, articles, reports, webpages, or other sources, use sentence case – capitalize only the first letter of the first word of the title and subtitle, the first word after a colon or a dash in the title, and proper nouns.

Italicize titles of longer works (e.g., books, edited collections, names of newspapers, and so on).

Do not italicize, underline, or put quotes around the titles of shorter works such as chapters in books or essays in edited collections.

Begin each appendix on a new page AFTER References.

Give each appendix a label and title. For one appendix, label it “Appendix”. If more then one, label each with a capital letter (A, B, C, etc.) in the order in which it is mentioned in the text. The appendix title should describe its contents.

The appendix title should describe its contents.

Each appendix should be mentioned at least once in the text.

Place the label and title in title case, bold and centered on separate lines at the top of the page on which the appendix begins.



No appendices needed for the Health History Assignment.

This is for future reference.












Health History Assignment – Part 2

Student Name

School of Nursing, Azusa Pacific University

GNRS 578, Health Assessment

Instructor’s Name



Health History Assignment – Part 2

No sample. Please include an introduction that frames the purpose and application/uses of

a health history. For guidance, refer to the beginning of Jarvis, Chapter 4.

Problem Lists

This patient is an 80-year old Caucasian female. The actual problems for this patient are

bilateral leg edema, difficulty walking, obesity, hypertension, hyperglycemia, joint pain, back

pain, depression, and anxiety. The potential problems for this patient include risk for clots due to

immobility, risk for diabetes mellitus, risk for dehydration, risk for fall and risk for infection due

to incomplete immunizations.

Assessment and Analysis

Patient Perspective of Presenting Problem

The presenting problem of bilateral leg edema is not much of a concern for the patient.

Since that patient has experienced this before and the edema has resolved with diuretics, the

patient believes that the edema will resolve with the same treatment. The edema does not

contribute to her anxiety nor impact her life. The patient only describes the edema as

inconvenient when she needs to wear shoes to go to her doctor’s appointments. The patient is

lying down most of the day, so she does not notice the leg swelling or weight gain from the

swelling. She states that the cardiologist has told her she does not have a heart issue and she

believes her edema is caused by her immobility. She reports that she needs to move around more

to possibly prevent water accumulation in her legs and avoid gaining more weight. The patient is

more concerned about her overall additional weight gain from the swelling, aside from her

sedentary lifestyle and overeating. The patient does not have any spiritual concerns that need to

be addressed.


Overview of Significant Concern Areas

The presenting symptom of edema of the bilateral lower extremities is the major concern

area for the patient with associated mild weight gain. Since the patient’s physician ruled out any

heart conditions, the patient believes her immobility is causing the issue and that she needs to

move around more. In one study that was conducted on individuals with gait disturbances and

without any venous abnormalities or systemic diseases, successful management of leg edema

was achieved through compression and physical therapy (Suehiro et al., 2014). With these

findings, it was assumed that leg edema was due to immobility that caused venous stasis

(Suehiro et al., 2014). Since the patient has difficulty walking herself, she should get help from

outside sources, such as physical therapists and compression therapy as suggested by evidence-

based research. With the patient lying down most of the day and usually only noticing her leg

edema when she must wear shoes, the patient must also pay more attention to the swelling

variations of her lower extremities. While the presenting problem of bilateral leg edema does not

cause the patient much suffering, it is important for the patient to monitor daily weight changes

to notice worsening symptoms. Daily weight monitoring allows for early detection of excess

fluid volume which can be balanced out with medication increases to prevent the need for

hospitalization (Wagner & Harden-Pierce, 2014, as cited in Ackley et al., 2020).

The patient also has difficulty walking, which causes her to walk extremely slowly. The

patient should start to walk more during the day, even if it means walking for a few minutes and

gradually progressing her way up the block. Even slow walking with turns can preserve muscle

mass and strength, facilitating further independence (Araki et al., 2017, as cited in Ackley et al.,

2020). Walking can also prevent venous stasis, which is a risk factor for clots (Huether &

McCance, 2020). As discussed above, the patient’s issue of having difficulty walking due to her


rheumatoid arthritis and back pain should be intervened by health professionals if the patient

cannot motivate herself. Another study done to increase physical activity in patients suffering

from rheumatoid arthritis, revealed that posttreatment and 6-month follow up appointments

greatly increased the number of patients meeting the physical activity recommendations (Knittle

et al., 2015, as cited in Ackley et al., 2020). Through motivation and professional management,

the patient can be guided in a specific direction and be encouraged to self-monitor her times

spent on physical activity and more.

Having a body mass index (BMI) of 32.9 kg/m2 put the patient in the obese category.

The patient notes that she does not exercise and barely moves around due to the pain in her

joints. She is aware that her sedentary lifestyle and overeating is contributing to her weight gain.

A moderate weight loss approach is suggested for the geriatric population with a BMI over 30

(Ackley et al., 2020). It is recommended to limit simple carbohydrate intake and instead focus on

balanced high-quality nutrients, which includes high-quality meats of around 1.2 g per kg of

body weight (Blaze, 2016, as cited in Ackley et al., 2020). Since the patient’s daughter makes

most of the food and rice is usually eaten with Persian dishes she makes, the daughter needs to

limit including it with the meals. Based on the patient’s weight, she should be limiting high-

quality meats to around 98 grams as well.

Since the patient has rheumatoid arthritis, gait difficulty due to pain and a history of falls,

the patient is at risk for falls (Potter et al., 2021). The patient’s most recent fall was caused by

slipping on the rug by her bed. The patient should remove any throw rugs, declutter her home

and install adequate lighting in the house to help prevent falls (Potter et al., 2021).

Chronic depression and anxiety have been an issue with the patient for many years and

both concerns are part of the patient’s family history. The patient reports feeling depressed or


anxious due to her inability to move about as she wishes. It has previously been found that 30 to

50% of chronic pain patients have depression as a comorbidity (Breivik et al., 2014, as cited in

Ackley et al., 2020). The patient states that she uses the television to distract herself most of the

time. If the patient begins to feel anxious or down, there are other techniques she can use to try to

feel better such as visualizing herself without anxiety and such, successful experiences of

situations or resolution of conflicts (Ackley et al., 2020). This strategy of guided imagery has

been used as a psycho-supportive intervention due to promoting comfort (Satija & Bhatnagar,

2017, as cited in Ackley et al., 2020).

The patient has a family history of colon cancer on her father’s side. New technology has

brought about the fecal immunochemical test (FIT) that detects blood from an ulcer or polyp in

the colon from an individual’s stool sample (Jarvis, 2020). With the patient having a family

history of colon cancer and having her last colonoscopy 3 years ago, the FIT test is a simple,

noninvasive tool that the patient can do annually to detect possible abnormalities of the colon

sooner. If the test is ever positive, the patient will then have to do a colonoscopy to confirm

colon cancer or determine the next steps (Jarvis, 2020).

Evaluation of Nutritional Data

The patient reports eating cheese as part of her breakfast meal every day. Since the

patient has a history of hypertension, she should become aware of foods that have high amounts

of salt in them, including dairy. It is recommended that people who have hypertension follow the

dietary approaches to stop hypertension (DASH) diet, which suggests reducing sodium intake to

less than 2300mg per day (Grodner et al., 2020). The patient also consumes rice regularly, which

is made with added salt by her daughter. One major way of reducing sodium intake is to avoid

adding salt when making rice (Grodner et al., 2020). Reducing salt intake can also help treat the


patient’s presenting problem of bilateral leg edema (Huether & McCance, 2020). The daughter

can take pre-portioned meals instead of a large container of rice to help the patient lose calories

since she is considered obese and is not exercising. During breakfast, the patient usually has

bread as well. Since the patient is eating a similar breakfast daily, she should substitute her bread

for a whole-grain bread. This will help fulfill the suggesting seven to eight servings of grain

products, that increases intake of minerals and fibers (Grodner et al., 2020). Chocolate and ice

cream is eaten just about every day too, which can contribute to high amounts of sugar. Not only

does the patient have to reduce this intake to adhere to the recommended 5 servings a week of

the DASH diet (Grodner et al., 2020), the patient needs to decrease her sugar intake because of

her diagnosis of hyperglycemia and to reduce the risk of its progression to diabetes mellitus. In

addition to contributing to extra glucose and calories, the daily intake of ice cream is a source of

saturated fat and does not fulfill the recommended 3 servings of low fat or non-fat dairy products

(Grodner et al., 2020). The patient should instead turn to low fat or non-fat dairy products like

frozen yogurt to comply with the recommendations of reducing saturated fat and total fat or at

least buy a healthier version (Grodner et al., 2020).

Although the patient can apply many of these modifications, one of the patient’s strengths

is satisfying the recommended 4 to 5 servings of fruits per day (Grodner et al., 2020). Another

one of her strengths is eating fresh poultry, fish, and lean meats rather than fattier foods or cured

meat (Grodner et al., 2020). The patient does not really consume fatty foods. While the older

population is more at risk for Vitamin D deficiency (Grodner et al., 2020), the patient does take

supplements to prevent this, especially since she is not under the sun much. While it is currently

unlikely, it is possible for the patient to become deficient in Vitamin B12 later due to the general

decrease of intrinsic factor production in the older population, which helps with absorption


(Grodner et al., 2020). The patient notes drinking about 4 cups of water a day, rather than the

recommended 8 glasses (Grodner et al., 2020). Due to the patient’s presenting problem of

bilateral leg edema, the amount of water the patient drinks should be discussed with her

physician to prevent further complications.


Nursing Diagnosis


Excess fluid volume related to excessive sodium intake as evidenced by peripheral edema

and weight gain.



Interventions Rationale for


Evaluation of Each


Patient will explain

at least two actions

that are needed to

treat or prevent

excess fluid volume

including dietary

restrictions and

medications as well

as maintain the

appropriate body

weight of 178

pounds within the

next 6 weeks.

1a) RN will assist

patient in switching

to a restricted-

sodium diet and

will teach patient

how to

appropriately take

diuretics prescribed

by the provider.

1b) RN will help

patient monitor

daily weight for

sudden increases

using the same

scale and type of

clothing at the same

time each day,

preferably before


1a) Restricting the

sodium in the diet

will favor the renal

excretion of excess

fluid (Rudge &

Kim, 2014 as cited

in Ackley et al.,

2020, p. 414).

…diuretics should

be initiated in

the…client who

presents with

significant fluid


reduce morbidity

(Yancy et al., 2013

as cited in Ackley

et al., 2020, p. 194).

1b) Body weight is

commonly used to

monitor for fluid

overload (Wagner

& Harden-Pierce,

2014 as cited in

Ackley et al., 2020,

p. 413).

1a) Goal met. Patient was

able to explain two

actions that are needed to

treat or prevent excess

fluid volume: avoiding

bringing the saltshaker to

the table during meals

and checking her blood

pressure before taking

one dose of diuretics in

the morning then the

second dose no later than

4 p.m. as prescribed.

1b) Goal met. Patient

reports a noticeable

decrease in peripheral

edema and is now

weighing at 178 pounds

each morning before

breakfast using the same

scale and type of clothing

after adhering to a

restricted-sodium diet

and use of diuretics.



Ackley. B. J., Ladwig, G.B., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2020).

Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.).


Grodner, M., Escott-Stump, S., & Dorner, S. (2020). Nutritional foundations and clinical

applications: A nursing approach (7th ed.). Elsevier.

Huether, S., & McCance, K. (2020). Understanding pathophysiology (7th ed.). Elsevier.

Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.

Potter, P., Perry, A., Stockert, P., Hall, A. (2021). Fundamentals of nursing (10th ed.). Elsevier.

Suehiro, K., Morikage, N., Murakami, M., Yamashita, O., Ueda, K., Samura, M., & Hamano, K.

(2014). A study of leg edema in immobile patients. Circulation Journal: Official Journal

of the Japanese Circulation Society, 78(7), 1733–1739.


APA FORMAT – QUICK GUIDE (with locations in APA Publication Manual, 7th ed.)

Sources for help with APA format:

• APU Writing Center

• Purdue Online Writing Lab (OWL)


No running head, author note or abstract unless
specifically asked for by instructor (2.2, 2.8)
Title page elements (2.3)
title, author(s), affiliation, course number & name,
instructor name, and due date
Title (2.4) title case, bold, centered, upper half of pg.
Put in one blank double-spaced line between
title and byline (2.5)


Put title of paper on first line of the first page of text
(2.11) title case, bold, centered
Appendices (2.14) – begin each on a separate page,
give each a label and title (on separate lines,
sentence case, bold, centered)
Order of pages (2.17)
title page, text, references, appendices
Page numbers (2.18) – insert page numbers in the
top right corner, title page is page number 1
Keep consistent double-spacing (2.21)
– do not add blank lines before or after headings
– do not add extra space between paragraphs
– MS Word Line Spacing – 3-minute video describes

how to set your paper for correct line spacing

One-inch margins – keep consistent (2.22)
Right margin – do not justify (2.23)
Indent first line of every paragraph (2.24)
No header or title for introduction (2.27)
Headings format – see chart on this page (2.27)


Tighten language to eliminate wordiness (4.6)
Avoid contractions and colloquialisms (4.8)
Revise your final draft (4.30) into a polished
paper by reviewing central points, assignment
parameters and assignment rubric, if provided
Check and proofread for spelling and grammar!



Insert one space following punctuation at the
end of sentences (6.1)
Comma (6.3) – see APA manual for a full list of uses
Use to set off the year in parenthetical in-text
citations, e.g. (Horowitz, 2019, p. 214)
Sentence case (6.17) – in a title or heading lowercase
most words and capitalize only these: first word of
title or heading, first word of subtitle, first word
after a colon, em dash, end punctuation in a
heading, nouns followed by numbers or letters,
and proper nouns
Title case (6.17) – in a title or heading capitalize the
first word, first word of subtitle, first word after
a colon, em dash, end punctuation in a heading,
major words, and word of four letters or more
(With, Between, From)
Italics (6.22) – see APA manual for full list
Use italics for: title of books, reports, webpages,
periodicals, and periodical volume numbers in
reference lists
Abbreviations, use and definition (6.24, 6.25)
– use it at least three times in the paper
– do not define abbreviations that are listed as

terms in the dictionary (e.g., AIDS, IQ)
– when the full version of a term is first used in a

sentence in the text, place the abbreviation in
parenthesis after it. e.g., attention-
deficit/hyperactivity disorder (ADHD)

Numbers (6.33) – spell out (use the word for)
numbers zero through nine and for any number
that begins a sentence


Each work cited must be in the reference list
and vise-versa (8.4)
Secondary source citation format (8.6)
In-text citation format (8.10)
With parenthetical citation at the end of a
sentence, put period or other end punctuation
after the closing parenthesis.
Citing multiple works (8.12)
separate multiple citations with semicolons
Unknown or anonymous author (8.14)
Number of authors for in-text citations (8.17)
– 3 or more use et al. every time, including first time
– use an ampersand in parenthetical citations
– spell out “and” in narrative citations

Direct quote (8.25) – always provide page number
Single page “p. 2”. Multiple pages “pp. 2-6” (8.25)


Start on a new page (2.12, 9.43)
Label with “References”
capitalized, bold, centered (2.12, 9.43)
Punctuation for entries (9.5) – see APA manual
periods, commas, and parentheses
Identify author correctly (9.7, 9.11)
– an institution, government agency or organization

is considered the author unless otherwise specified
– see examples 111 & 112 in chapter 10 (10.16)

Provide surnames and initials (9.8)
– no first names or credentials
– for up to 20 authors

Use a serial comma before ampersand that
comes before last author’s name (9.8)
One space between initials (9.8)
No author format (9.12)
Group authors (9.11) – including gov. agencies,
associations, hospitals, businesses

– spell out organization name in the reference list
unless it does not appear this way

– an abbreviation for the group author can be
used in the text

Retrieval dates are not needed for the
majority of references (9.16, 10.16)
If the title ends in a question mark or exclamation
point, that punctuation replaces the period (9.19)
Sentence case (9.19) – see APA manual
Periodical sources format (9.25)

– title as shown on the work (use title case, italics)
– volume (italics)
– issue (in parenthesis with no space after volume)
– page range or article number
– end with a period
– follow with DOI or URL as applicable

Italics (9.19, 9.25) – see APA manual
Publisher’s location (9.29) – do not include
Designations of business structure (9.29) – do not
include; no Inc., Ltd., LLC
Write author’s name as it appears in the published
work; retain preferred capitalization (9.9)
DOIs & URLs format (9.35)

– no “Retrieved from…”; links should be live
– no period after

Alphabetize (9.43)
Double-space the ENTIRE reference page (9.43)

– within and between entries
– double space after the label References

Hanging indent (9.43) – apply to each entry
Format for “edition” is ed. (9.19 & 9.50) e.g., 8th ed.

DMay Rev 10/2022

Health history assignment part 1

Section 1: Biographic Data

N.V is a 46-year-old married Iranian woman, who currently is a full-time financial manager at BMW company. She speaks fluent English and does not require an interpreter.

Section 2: Source of History

The patient provides the information herself. The patient seems reliable, as she is alert and oriented.

Section 3: Reason for Seeking Care

The patient states, “I am really exhausted and want to get rid of my leg pain. I have severe pain in my thighs and legs and it started six years ago.”

Section 4: History of Present Illness (HPI)

The patient’s thigh and leg pain began six years prior to the interview. Her pain started following the birth of her second child. The patient has frequent episodes, the last being three days ago. It has never been resolved. It is specially located in the thighs and legs, sometimes includes back pain, and does not radiate to other regions. It mainly felt in the evening and at bedtime when the patient sitting or lying down. The duration is vary depending on the amount of activity that the patient has on that day, the longest being 48 hours and the shortest being 1 hour. The patient feels dull pain in the muscles that rates as 6 on the pain scale from 0 to 10. Lying down aggravates the symptoms. The patient has been using warm compresses and pressure massage to relieve pain. No treatments have been used. The patient denies having medical, surgical, or psychiatric conditions that are significant to the current condition.

Review of Related Body System- Musculoskeletal:

Patient reports having muscle pain in her legs. She sometimes experiences back pain as well. She feels the pain in the evening and at bedtime when the patient sitting or lying down. The patient denies cramps, weakness, coordination problems with activities, mobility aids, or assistive devices used. The patient denies arthritis, gout, or any pain, stiffness, swelling, deformity, or noise in her joints.

Health Promotion: Patient states that she walks about 500-1000 steps per day at work.

Section 5: Past Health

Childhood Illnesses

Patient has had mumps and denies a history of chicken pox, measles, rubella, pertussis, and strep throat. The mumps was lasts for two weeks and were treated by bed rest, plenty of fluids, and painkillers. There were no complications.

Accidents or Injuries

patient denies any accidents or injuries.

Serious or Chronic Illnesses

patient denies any serious illnesses. Denies history of asthma, depression, diabetes, hypertension, heart
disease, HIV infection, hepatitis, sickle-cell anemia, cancer, and seizure disorder.


patient reports being hospitalized for nose surgery at Mahan hospital in 1996 for one night and two vaginal deliveries, at Cedars-Sinai hospital in 2001 and at Mission hills hospital in 2016. She was treated with ibuprofen for pain, and had no other complications.

Patient has nose cosmetic surgery in 1996 at Mahan hospital in Tehran, Iran with Dr.Akbari. she stays one night at the hospital. She was prescribed pain medication during recovery.

Obstetric History

Gravida: 2

Term: 2

Preterm: 0

Ab: 0

Living: 2

The first pregnancy reached full term at nine months and was two weeks late before delivery. It was a vaginal delivery. The baby was a male, 7.2 Ib., and healthy. The second pregnancy reached full term at nine months and was one week late before delivery. It was a vaginal delivery. The baby was a male 7.5 ib., and healthy. Patient denies postpartum complications with both pregnancies.


Patient states that she has no record of previous immunizations, due to the records being lost.

Psychiatric History

Patient denies psychiatric history.

Last Physical Examination

Last examination was April 2022. Vitamin D deficiency and a borderline thyroid. No other abnormal finding.


Patient has allergies to eggplant and pepper, which cause rashes and itching. The patient notes do not use any medication for her allergy. NKDA.

Current Medications




Reasons for Medication



500 mg, tablet, PO

Improve immune

Vitamin D-3


25 mcg, 1 drop, PO

Improve D deficiency



250 mg, tablet, PO

Improve hair growth



600 mg, tablet, PO

Pain relief

Patient denies taking aspirin, antacids, or cold remedies. Denies any home or herbal remedies.

Section 6: Family History

Mother, living, age 81, history of hypertension. Father, living, age 87, history of prediabetes. Sister, living, age 61, history of uterus cancer, and lung cancer. Brother, living, age 55, history of hypertension. Brother, living age 58, healthy. Brother, living, age 50, healthy. Maternal grandmother, deceased, age 65, bone cancer. Maternal grandfather, deceased, age 67, prostate cancer. Paternal grandmother, deceased, age 85, healthy. Paternal grandfather, deceased, age 72, history of diabetes type 2. Husband, living, age 52, history of hypertension. Son, living, age 20, healthy. Son, living, age 6, healthy.

Patient denies family history of coronary heart disease, stroke, obesity, blood
disorders, alcohol or drug addiction, mental illness, suicide, kidney disease, and


Section 7: Review of Systems (ROS)

General: The patient states that she considers herself to be healthy. She recently starts gaining weight. Patient deny any other illness, fatigue, weakness, malaise, fever, chill, sweat or night sweat.

SKIN, HAIR & NAILS: Patient denies history of skin disease, rashes or lesions, pigment or color change, change in moles, excessive dryness or moisture, pruritus, and excessive bruising. Recently, her hair started to fallen in the last 1 year ago.

Health Promotion: Patient states she uses sunscreen (UVA/UVB SPF 35) only on her face. Patient does not use sunblock on entire body daily. Patient Denies using indoor tanning beds. Patient denies performing monthly skin self-examination. Patient states she is in sun 2 to 3 hours a day.

Head: No abnormal findings. Patient denies severe headaches, head injuries, dizziness, and vertigo.

Health promotion: She always uses seat belt and drive through speed limits while driving.

Eyes: Patient states she does not have clear sight for far objects, but she never met any physician and does not try any treatment. Patient denies blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, history of glaucoma or cataracts.

Health promotion: Patient states fatigue weaken her eye sight too.

EARS: Patient denies any earaches, infections, discharge and its characteristics, tinnitus, or vertigo. No hearing loss or usage of hearing aid. Patient states she cannot recall her last evaluation with a physician.

Health promotion: The patient cleans her ears regularly. Patient notes she is exposed to light environmental noise.

NOSE & SINUSES: Patient states she had cosmetic surgery on her nose 27 years ago. She denies any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies, hay fever, or change in sense of smell

MOUTH & THROAT: Patient denies any frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, bad breath, history of tonsillectomy, or altered taste. The patient states her voice sounds hoarse sometimes.

Health Promotion: Patient brushes her teeth twice a day and flosses every night before bed. Dentist cleaning appointment once a year. The last dental visit was on 09/22, Dr. Mousavi, had no abnormal results including cavities.

Neck: No abnormal findings. Patient denies pain, limitations of motion, lumps, swelling, lumps, enlarged or tender nodules, goiters, and recent neck injuries.

Breast/Axilla: No abnormal findings. Patient denies breast pain, or unusual nipple discharge, or history of breast surgery or implants. She founded a lump in her left breast and diagnosed with fibroadenoma but states no treatment has been used for it.

Health Promotion: Patient does breast self-examination every month and last mammogram was in 2021, result shows no abnormal finding.

RESPIRATORY: Patient denies any lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), shortness of breath. She states she is exposed to a clean environment to breathe. The patient states she cannot recall her last TB test and chest X-ray.

Cardiovascular: Patient denies chest pain, palpitation, cyanosis, orthopnea, paroxysmal nocturnal dyspnea, history of heart murmur, coronary artery disease, heart failure, and previous MI. Patient states she cannot recall her last EGG or other cardiac tests.

Peripheral Vascular: patient denies coldness, numbness, tingling, swelling of legs, discoloration, intermittent claudication, thrombophlebitis, and ulcers. The patient has varicose veins in her right calf, and the patient states that she doesn’t know when to get them.

Health Promotion: The patient reports some days has prolonged sitting or standing. The patient notes to always crosses her legs at the knees and not wear a support hose.

GASTROINTESTINAL: Patient denies any nausea, vomiting, hematemesis, dysphagia heartburn, reflux, indigestion, abdominal pain, abdominal disease, excessive belching or flatulence. She has bowel movements two or three times a day. She also denies any recent change in stool characteristics, constipation or diarrhea, black or tarry stools, rectal bleeding, rectal conditions such as hemorrhoids or fistula.

Urinary: Patient states she has no nocturia and urinates 3 times a day. Patient notes urine is a lighter yellow, no presence of hematuria. Patient denies dysuria, polyuria, oliguria, hesitancy, straining, narrowed stream, kidney disease, kidney stones, urinary tract infections and incontinence.

Genital Female: Patient states having begun her menses at age 12. She states has regular menstruation, with 5 days, every 28 days. Her last menstrual period starts on 28th September till 2th October. The patient notes having weak pain during menstruation, but denies having bleeding between periods or after intercourse, vaginal discharge, or itching.

Sexual Health: Patient is sexually active. Patient denies being exposed to gonorrhea, herpes, Chlamydia, HPV, HIV/AIDS, or syphilis. The patient denied HPV vaccine, and notes never having had an STD test.

Musculoskeletal: See History of Present Illness.

Neurologic: Patient denies history of seizures, strokes, syncope, paralysis, local weakness, numbness, tingling, or tremors. Pt denies changes in memory or concentration, changes in mood, tension, nervousness, depression, hallucinations, or suicidal thoughts.

Health Promotion: Patient does not recall having the meningococcal vaccine due to immunization records being lost.

Hematologic: Patient denies having anemia, easy bruising, or bleeding and having a history of blood transfusions.

Endocrine: Patient denies diabetes, heat or cold intolerance, excessive sweating, excessive thirst, eating, or urination. she states she has borderline thyroid but does not use medication for it.

Health Promotion: Patient cannot recall the date of the last glucose test but denies ever having an abnormal result.

Section 8: Functional Assessment

Self-Esteem/Self Concept

The Patient has a diploma from her backcountry in 1994. No history of military service. The patient is currently employed full-time, 45 hours a week, as a financial manager at BMW Rusnak. The patient is highly satisfied. The patient denies having any current health problems now that may be related to this health exposure. Patient denies working with health hazards such as asbestos, inhalants, chemicals, or repetitive motions. Patient confirms having health insurance.

Activity / Exercise

The patient reports being comfortable with all daily activities, such as eating, bathing, hygiene, dressing, walking, standing, and climbing stairs. No use of assistive devices was reported. Patient states achieving one hour of exercise every day through working, and cleaning.

Sleep / Rest

Patient reports sleeping 5-6 hours a night. She goes to bed at 2300 and wakes up at 0500. The patient has difficulty with insomnia a couple of times a week. Patient not seeking treatment for insomnia. Patient does not use medication to fall asleep.


The patient is 5”8 and 155 Ib., with a BMI of 23.6 kg/m2. The patient’s intake within the last 24 hours consists of: Breakfast: 1 boiled egg – 2 slices whole grain bread- ½ cup cucumber- 1 medium size tomato- 1 cup tea – 1 tablespoon honey. At 1100: 1 cup of blueberry- 20 oz of water. Lunch: 0.5 Ib. salmon fish- 6 tablespoons white rice- 1 cup cooked broccoli and carrot- 1 cup salad (chopped cucumber-onion-tomato with lemon juice and olive oil)- 1 cup low-fat yogurt drink- 20 oz of water. At 1600: 2 scoops ice-creams – 18 oz of water. Dinner: 10-ounce pasta with fried ground beef and tomato sauce and 2 tablespoons parmesan cheese – 2 tablespoon ketchup sauce- ½ cup fat-free yogurt- 20 oz of water. The patient states that “this can be” a typical daily diet for most days. The Patient prepares her own food. The patient has sufficient finances for food. She describes eating with her husband and coworkers for most mealtimes. She has food tolerance to eggplant and pepper due to an allergy. The patient reports not drinking coffee and has a protein base diet.

Interpersonal Relationships/Resources

Patient has been married for 26 years, and a mother of 2 for 20 years. The patient notes she and her husband share expenses in the family. The patient states that she is close to her sister and husband, but she goes to a friend or God to seek emotional support.

Spiritual Assessment

Patient denies any specific religion and states that she just believes in God. She explains God has a huge impact on her life and she prays to Him sometimes. She doesn’t belong to any community. And denies speaking more in detail about it.

Coping and Stress Management

Patient notes the stress in her life is worrying about her children’s future and her parents due to their age. The patient denies taking medication but distracts herself when gets stressed by music or doing shopping. The patient notes a personal strength is being helpful to others.

Environment / Living Conditions

Patient lives at the house with her family. Patient reports that their home has no stairs, and is located in a safe neighborhood, with sufficient utilities and heat. The patient owns her own vehicle and can drive herself.

intimate Partner Violence / Elder Abuse

Patient denies any abuse, harm, or emotional harm from either her husband or family. The patient states that she feels safe around the members of her family.

Personal Habits

Tobacco: patient denies any tobacco use.

Alcohol: patient denies alcohol consumption.

Drugs (medication & recreational/illicit): patient denies drug use.

Cultural, Ethnic and Racial Background:

Patient identifies as Iranian, and culturally considers herself to be Caucasian. The patient notes being born in Tehran, Iran, and moving to The United States, California, when she was 22 years old and where she remains living to this day. The patient denies practicing any cultural or ethnic traditions that may relate to her health. Patient denies having any ethnic or cultural impactions on her choice of diet.

Section 9: Perception of Health

Patient’s goal is to minimize or eliminate the pain in her legs. the patient notes “she gets suffered for too long, she seeks treatment many times but they weren’t able to find an effective treatment.” “She reports that some nights she cries from pain and wanted their son to sit on her lap to reduce the pain”

Section 10: Problem Lists

Actual Problems: leg pain- back pain- insomnia- hoarse voice.

Potential/Risk Problems: borderline thyroid, lump in breast, varicose vein, visual impairment, hair loss, weight gain, allergy.



Scoring System

Your score






How often do you have a drink containing alcohol?


Monthly or less

2-4 times

Per month










How many units of alcohol do you drink on a typical day when you are drinking?







How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?


Monthly or less














TOTAL SCORE: ___0___

Scoring: Total of 5+ indicates increasing or higher risk drinking.

An overall total score of 5 or above is AUDIT-C positive.

Remaining AUDIT – C questions


Scoring System

Your score






How often during the last year have you found that you were not able to stop drinking once you had started?


Less than monthly



Daily or almost daily


How often during the last year have you failed to do what was normally expected from you because of your drinking?


Less than monthly



Daily or almost daily


How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?


Less than monthly



Daily or almost daily


How often during the last year have you had a feeling of guilt or remorse after drinking?


Less than monthly



Daily or almost daily


How often during the last year have you been unable to remember what happened the night before because you had been drinking?


Less than monthly



Daily or almost daily


Have you or somebody else been injured because of your drinking?


Yes, but not in the last year

Daily or almost daily


Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?


Yes, but not in the last year

Daily or almost daily


Scoring: 0-7 Lower risk, 8-15 Increasing risk, 16-19 Higher risk, 20+ Possible dependence

TOTAL score equals =

AUDIT C Score (above) + Score of remaining questions

TOTAL SCORE: ___0___

Drug Screening Questionnaire (DAST – 10)

Using drugs can affect your health and some medications you may take. Please help us provide you with the best healthcare by answering the questions below. When the words “drug abuse” are used, they mean the use of prescribed or over-the-counter medications/drugs in excess of the directions and any non-medical use of drugs.

Which recreation drugs have you used in the past 12 months?

☐ Methamphetamines (speed, crystal)

☐ Cannabis (marijuana, hash)

☐ Inhalants (paint thinner, aerosol, glue, etc.)

☐ Tranquilizers (valium)

☐ Cocaine (crack)

☐ Narcotics (heroin, hydrocodone, oxycontin, etc.)

☐ Other __________None___________



Nursing Process – SAMPLE Nursing Diagnosis

NANDA (North American Nursing Diagnosis)

Chronic Pain
related to unknown etiology
as evidenced by self-reports of pain “I feel pain when sitting or lying down mostly at night” using a standardized pain scale, 4/10 on a 0 to 10 numeric rating scale. The patient reports an altered sleep-wake cycle.

Patient Goal/Outcome


Rationale for Interventions

Evaluation of Each Goal/Intervention

1)The Patient’s pain will reduce and her sleep will promote by using nonpharmacological methods such as supplements or enhance pharmacological interventions within the next three months.

1a) RN will in addition to administering analgesics, support the client’s use of nonpharmacological methods to help

control pain, such as distraction, imagery, relaxation, and application of heat and cold.

1b) RN will ask the client to describe prior experiences with pain, effectiveness of pain management interventions,

responses to analgesic medications (including occurrence of side effects), and concerns about pain and

its treatment (e.g., fear about addiction, worries, anxiety) and informational needs.

1a) Evidence

suggested efficacy and satisfaction when complementary therapies are integrated into pain treatment plans of

older adults (Bruckenthal, 2016 as cited in Ackley et al., 2022, p. 723).

1b) Sleep disturbance and decreased physical activity are adverse

effects of people with chronic pain. In a study of clients with chronic pain, those who participated in a 4 week

multiprofessional program that included psychoeducation and training related to pain, sleep, exercise, and

activity training had improvement in sleep quality and pain intensity (de la Vega, 2019, as cited in Ackley et al., 2022, p. 721).

1a) Goal partially met. Patient’s pain decreased to level 2/10, with relaxation therapy such as meditation and usage of heat pads.

1b) Goal met. Patients starts to drink Valerian root tea and states “It reduced the amount of time takes me to fall asleep and helped me sleep better.”

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