Nursing Process – SAMPLE Nursing Diagnosis NANDA (North American Nursing Diagnosis) Chronic Painrelated 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 Interventions 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.” 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 .

1. Nursing Process – SAMPLE Nursing Diagnosis
NANDA (North American Nursing Diagnosis)
Chronic Painrelated 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
Interventions
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.

2. 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.

3. 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.”
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

4. 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,

5. depression, diabetes, hypertension, heart
disease, HIV infection, hepatitis, sickle-cell anemia, cancer, and
seizure disorder.
Hospitalizations
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.
Operations
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.
Immunizations
Patient states that she has no record of previous immunizations,
due to the records being lost.
Psychiatric History
Patient denies psychiatric history.

6. Last Physical Examination
Last examination was April 2022. Vitamin D deficiency and a
borderline thyroid. No other abnormal finding.
Allergies
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
Name
Date
Dose
Reasons for Medication
Multivitamin
QD
500 mg, tablet, PO
Improve immune
Vitamin D-3
QD
25 mcg, 1 drop, PO
Improve D deficiency
Hairtamin
QD
250 mg, tablet, PO
Improve hair growth
Ibuprofen
PRN
600 mg, tablet, PO
Pain relief
Patient denies taking aspirin, antacids, or cold remedies. Denies
any home or herbal remedies.

7. 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
tuberculosis.
genogram
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.

8. 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

9. 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

10. 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.

11. 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

12. 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.
Nutrition
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

13. 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

14. 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.
AUDIT – C
Questions
Scoring System
Your score

15. 0
1
2
3
4
How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times
Per month
2-3
times
per
week
4+
times
per
week
0
How many units of alcohol do you drink on a typical day when
you are drinking?
1-2
3-4
5-6
7-9
10+
0
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?
Never
Monthly or less
2-4
times
per
month

16. 2-3
times
per
week
4+
times
per
week
0
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
Questions
Scoring System
Your score
0
1
2
3
4
How often during the last year have you found that you were not
able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
How often during the last year have you failed to do what was

17. normally expected from you because of your drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
How often during the last year have you needed an alcoholic
drink in the morning to get yourself going after a heavy
drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
How often during the last year have you had a feeling of guilt or
remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
How often during the last year have you been unable to
remember what happened the night before because you had been
drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
Have you or somebody else been injured because of your
drinking?
No

18. Yes, but not in the last year
Daily or almost daily
0
Has a relative or friend, doctor or other health worker been
concerned about your drinking or suggested that you cut down?
No
Yes, but not in the last year
Daily or almost daily
0
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___________

19. image1.png
image2.png
APA FORMAT – QUICK GUIDE (with locations in APA
Publication Manual, 7th ed.)
Sources for help with APA format:
• APU Writing Center
https://www.apu.edu/writingcenter/
• Purdue Online Writing Lab (OWL)
https://owl.purdue.edu/owl/purdue_owl.html
TITLE PAGE (Chp 2)
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)
BODY OF PAPER (Chp 2)
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,

20. 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
https://www.youtube.com/watch?v=FIe_9FhV2jk
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)
WRITING STYLE & CLARITY (Chp 4)
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!
bold
https://www.apu.edu/writingcenter/

21. https://owl.purdue.edu/owl/purdue_owl.html
https://www.youtube.com/watch?v=FIe_9FhV2jk
MECHANICS (Chp 6)
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)

22. Numbers (6.33) - spell out (use the word for)
numbers zero through nine and for any number
that begins a sentence
IN-TEXT CITATIONS (Chp 8)
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)
REFERENCE LIST (Chp 9 & 10)
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

23. 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

24. 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
1
Health History Assignment – Part 2
Student Name
School of Nursing, Azusa Pacific
University

25. GNRS 578, Health
Assessment
Instructor’s Name
Date
2
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

26. 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

27. 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.
3
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

28. 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).

29. 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
4
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

30. 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.

31. 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
5
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

32. 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

33. 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
6
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

34. 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

35. 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
7
(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.

36. 8
Nursing Diagnosis
NANDA:
Excess fluid volume related to excessive sodium intake as
evidenced by peripheral edema
and weight gain.
Patient
Goal/Outcome
Interventions Rationale for
Interventions

37. Evaluation of Each
Goal/Intervention
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

38. 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

39. time each day,
preferably before
breakfast.
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
overload…to

40. 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

41. 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

42. after adhering to a
restricted-sodium diet
and use of diuretics.
9
References
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.).
Elsevier.
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.

43. 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.
https://doi.org/10.1253/circj.cj-13-
1599
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.
https://www.apu.edu/writingcenter/

44. 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.
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. Introduction
2Includes an introduction that frames the purpose and

45. 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
2Restates 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
Perspective6Addresses:
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 Areas12Based on the information collected,
includes personal and family history information.
Citations are included to provide evidence/source to support
discussions. Evaluation of Nutritional Data
6Identifies 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
Diagnosis14Applies nursing process to one priority problem
identified.
Problem is within a nurse’s scope of practice.
Diagnosis is selected from NANDA (North American Nursing

46. 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.TOTAL
42Please see graded assignment in Canvas to view earned
points along with instructor comments and annotations.
When viewing assignment grading, look at comments in the

47. 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.

48. 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

49. 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.
Alphabetize!
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.

50. 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

51. 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.
Appendices
(2.14)
No appendices needed for the Health History Assignment.

52. This is for future reference.
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