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Physical Examination and Health Assessment


Task: Explain the various aspects of collateral contracts and contractual promises Provide a short account of the Physical Examination and Health Assessment.


The idea of Health history evaluation signifies a very methodical examination of every issue and aspect pertaining to the health of the client. The major factors to be checked in the health history assessment are medical reports, previous welfare report, inspection of the physical condition, and the health history (Jarvis, 2015). The major motive of conducting this test is to recognize the incorporative test parameters and to provide a description of the duties required to present a suitable level of attention and caution to the necessities of the patients and hence analyzing their response towards care (Wang et al. 2012). The information obtained by the process of Health history assessment may have either the subjective or objective character. If the information is provided by the patient directly which may have communicated using non-vocabulary gestures possibly subtle and unnoticeable in nature would be classified under the Subjective Data. Under this category, the significant data like address, information regarding the family of a patient, the current biological situation of the patient, etc. could be included. Different from this, the information gathered by the professionals like doctors and nurses by the means of various physical examinations which are palpable, and evident by various sense and perception. This could be considered as health history which opens the way to make medical interventions to alleviate the critical condition of the patient. The report presented here is about the evaluation of health history and a valid consideration of their thinking process, their actions, and the conduct to arrive at the compelled results. The report on physical examination and health assessment case explains the different processes and the experience of carrying out the assessment of the health history as per the case study provided.

Health History Assessment

  • Demographic data The 70-year-old lady Mercedes Garcia is an aborigine of the United States of America. English is her secondary language in which she struggles to have a conversation. She lives along with her which consists of her son and husband.
  • Physical dimensions and the insight of health Garcia weighs 138 lbs and 5’1” in height. In the very last period of two months, she got away from 2 pounds of weight. The patient has reported with the widespread joint pain. Although Garcia has negated the need for any medication to subdue her pain. After walking for a long period, the patient feels the symptoms of angina. It should also be noted that she drinks liquor on a constant basis.
  • Previous therapeutic history It was being informed by the family of Garcia that she has a condition of cardiac disease and high blood pressure.
  • Medical history of the family lineage The biological mother of Garcia had died because of cardiac arrest at a very young age. Her father also had a very long history of high blood pressure throughout his lifetime.

Review of the Physical Systems
The review of systems consists of checking the major organs and systems in the human body which may successfully reveal the symptoms or the problems the patient is going through.

IntegumentaryThe hair of Garcia is very thin and is particularly grey in color. The dermatology condition of the patient is of wrinkled and patchy patterns on her arms and face. Her nails are very small and there is a minor discoloration in the left toenail. Her facial epithelial skin indicated the evidence of sunburn.

Garcia had been suffering from some problems with her thyroid and TSH level which had made her lose some weight.

It was also been observed that the patient was suffering from some trouble in respiration and this condition occurs when the patient has undergone physical activity for a while.

Garcia had been with asymmetrical heartbeats in the ECG reading and suffers from pain in chest occasionally.

GenitourinaryThere had been two occurrences of blood in the urine.

Garcia had to face sometimes acute headache accompanied by fatigue.

Mental Status
Garcia possesses a very sound mind and mental health and has not demonstrated any symptoms of depression and dementia which are most common among the old generation.

Developmental Considerations
The patient had not shown any case f psychological changes or developmental considerations till. Since Garcia has covered the age of 70 years, she is now in the wisdom phase i.e. the 8th stage of her life span. A person is expected to show less metabolism and efficiency and comprehend everything in a much peaceful and lenient way. Garcia still could envision her deeds and had a very crystal-clear perception of the uprightness because of her experience in life.

Cultural Considerations
In the provided case study of Garcia, there are some cultural implications and considerations. The ethical circumstances of the patient are of Hispanic background. As per the nursing conventions special interventions should be made while contacting the patients who are of different cultural backgrounds. For better and considerate interaction and the relation between the patient and the nurse effective communication plays a very significant role especially when it pertains to the task of nursing an old Hispanic patient. To understand the extent of the cultural mix and adaptation formal words should be used to the patient.

Psychosocial Considerations
Garcia is very health conscious and is very bothered about the present condition. Hence she has a great desire to lead her life in a healthy way.

Body systems on which the physical systems are: -
The two systems which were subjected to the task of physical assessment were the respiratory system and the circulatory system because the patient was being diagnosed with hypertension and excessive loss of body fluids led to dehydration of the body.

Collaborative Resources
The data regarding the medical condition of the patient was being obtained by directly interviewing the patient.

The experience I have obtained by nursing Garcia in this physical examination and health assessment case was very pleasant and helpful to acquire some significant knowledge in maintaining interaction with a patient having a totally different cultural background. In this experience, I have studied that while nursing and taking care of the patient with considerably older age a nurse should demonstrate very tolerant and calm nature. While nursing Garcia, this approach had really helped in maintaining a cordial relationship and exchange of ideas. The whole interaction with the patient was very cordial and pleasant and generated new confidence in me to face similar conditions. Garcia has displayed immense affection and trust towards the staff and co-operated by providing all sorts of previous medical history and had confidence in providing her suppository record. Although I had faced a little difficulty in making proper verbal contact with her since she was from a Hispanic background and was only able to understand the English language partially. In order to perform lucrative communication with the patient, I had used non-verbal signs and gestures. This incident has made me understand the significance of non-vocabulary communication and has made me more optimistic to practice it further in future cases. Though I had expected a lot of difficulties when I came to know about Garcia in records, the real experience was not at all that difficult. Since I have acquired much experience from this case, I would try to carry out a similar task more diligently next time. I have also realized the importance of interpersonal skills by attending Garcia in the hospital. I was bound to with the sensitive demands of the patient in this physical examination and health assessment case. I had tried my best t maintain the composure by revealing my original personality and handling the patient with a very honest response. Since I was instructed by senior that in order to deliver premium quality care to the patient, a nurse should display some empathy and emotional involvement with the patient. I have followed this suggestion an it actually showed great results in my advancements.

Jarvis, C. (2015). Physical Examination and Health Assessment–. Elsevier Health Sciences.

Wang, C., Sen, A., Ruffin, M., Nease, D., Gramling, R., & Acheson, L. et al. (2012). Family History Assessment. American Journal Of Preventive Medicine, 43(4), 392-398.


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