The document provides an overview and instructions for several chapters in the student's health assessment course. It outlines key topics and concepts to focus on for each chapter, including pain assessment, nutritional assessment, skin assessment, and head/neck assessment. For the health history assignment, it emphasizes collecting subjective data through a complete health history interview. Students should focus on chief complaint, present and past health histories, family history, review of systems, and functional assessment.

1. 1
B344: Comprehensive Health Assessment
Week 2/Module 2 Student Notes
Module 2 reading assignment is chapters 10, 11, 12 & 13.
Chapter 10: Pain Assessment: The Fifth Vital Sign
This chapter goes into great detail on pain, but just know the
basics:
· Difference between nociceptive and neuropathic pain
· Types of pain: acute vs. chronic
· Infants feel pain, and pain does not diminish in older adults;
pain is not a normal part of aging
· Note the types of information to obtain about pain (p. 164)
· Most often pain is measured using a rating scale, such as the
0-10 scale, or a faces scale for preverbal or nonverbal patients
· Note Table 10-2 (p. 172) for info on nociceptive and
neuropathic pain
Chapter 11: Nutritional Assessment
Things to concentrate on for this chapter:
· Know the discussion on 24-hour food recall and food diaries
(p. 180)
· Note MyPyramid info on p. 181; this information is no longer
accurate. The MyPyramid.com website has been replaced by
http://www.MyPlate.gov , there you will find information that
will be useful for the pediatric nutritional assessment
· Note Table 11-5: clinical signs of malnutrition
· Note the ranges for interpreting BMI for adults and children
on p. 187 (pink portion of the page)
· Other nutritional measures: waist-to-hip ratio and waist
circumference, skinfold thickness, and mid-upper arm
circumference
· Routine labs used include serum glucose and glycosylated
hemoglobin (HbA1c), hemoglobin and hematocrit, cholesterol
and triglycerides, serum proteins or serum albumin

2. · Note p. 194 on the obesity epidemic in this country; the
current generation of children are the first in recorded history to
have a predicted shorter life span than their parents, and this is
due to the dramatic rise in obesity, especially among children.
For more startling info, go to: www.cdc.gov; under ‘Multimedia
& Tools’, click on ‘BMI Calculator’. Here, under ‘Related
Links’, click on ‘Overweight & Obesity’; here, click on Obesity
Data & Statistics (More button); finally, click on ‘Trends by
State, 1985 – 2009. Watch how obesity has changed in this
country since the 1980’s.
· In the text’s Abnormal Findings section, read about obesity,
marasmus, and kwashiorkor; also know the basics of Metabolic
Syndrome on p. 200.
Chapter 12: Skin, Hair and Nails
This is the first body system. All chapters begin with a review
of structure and function. Review this content to better
understand assessment and findings. Things to pay particular
attention to:
· Note the difference between eccrine glands and apocrine
glands (p. 205)
· For infants, know lanugo and vernix caseosa; know that the
infant’s skin is relatively more permeable than that of older
people, making them at more risk for fluid loss and dehydration;
it also means that topical meds can have more of a systemic
effect than expected;
· For the pregnant woman, know linea nigra, chloasma, and our
friend striae gravidarum (although many of you might know that
striae can occur outside of pregnancy, alas)
· Under culture and genetics, please know that the correct
information is that: Blacks may be at more risk for keloid
formation, but it does not occur solely in Blacks, but also in
other persons of color (Hispanics, American Indians and
Asians) and some Caucasians; pseudofolliculitis, as well, can
occur in any male, not just in Blacks;
· Know the changes in moles suggestive of neoplasm on p. 207,

3. and more specifically on p. 212: ABCDE; know mole/nevus, and
vitiligo;
· Know the terms pallor, erythema, cyanosis, and jaundice;
· Know how to test skin turgor on p. 215; a very common
mistake is to use the skin on the back of the hand for this, but
this is NOT a reliable place to test this- all too often you can
get tenting in older people just because of how thin the skin has
become in this area; (my grandsons enjoy playing with the skin
on the back of my hand because of this!); it is best to use the
skin of the forearm or the chest below the clavicle; for infants,
we typically use the skin on the abdomen;
· Know angioma, and lesion (p. 216), which is a fairly general
term; understand primary vs. secondary lesions;
· For the nail, know clubbing (p. 218) which this text refers to
as the profile sign (can’t say that I’ve ever heard it called that
before, but its examining the nailbase in profile; other texts also
have you assess this by having the patient place two fingers
together, fingertip to fingertip (nail to nail) to look for the
diamond shape that should normally form in the space between
the nails; know normal vs. abnormal angle;
· Also know capillary refill on p. 219; this text states that
delayed refill takes longer than 1-2 seconds; others say 3
seconds or more; I won’t ask about a specific time;
· Know Mongolian spot, café au lait spots, acrocyanosis and
cutis marmorata, physiologic jaundice, vernix caseosa, and
milia, storkbite and lanugo all under normal findings;
· Under the aging adult, know senile lentigines (the actual name
for liver spots), seborrheic keratosis; the picture on p. 226
shows tenting, using- get this- the back of the hand! Don’t do
this; use the forearm, or chest skin below the clavicle; in infants
and children it is best to use the abdomen;
· It is not necessary to know the various ways to describe
lesions on p. 230-231; know the basic terms macule, papule,
nodule, wheal, vesicle, bulla, cyst, pustule, crust and scale;
know the terms on p. 234-235;
· P. 236 notes the different stages of decubitus ulcer formation,

4. which is important content; also know the basic lesions caused
by abuse on p. 237;
· Know petechiae, ecchymosis, candidiasis/intertrigo, impetigo;
know the distinguishing features of the disorders on pages 242-
244; do know the characteristics of malignant skin lesions,
however, which begin on p. 245, and of Kaposi sarcoma on p.
246;
· Under abnormal nail conditions, know beau’s line, pitting, and
clubbing;
Chapter 13: Head, Face, and Neck, Including Regional
Lymphatics
This is the last chapter for this unit. Review the structure and
function to refresh your memory. Things to know for this
chapter:
· Know how the sternomastoid muscle divides the neck into two
triangles (p. 253), which will be used as landmarks when
assessing neck structures;
· Know the landmarks for locating the thyroid gland (p. 254);
· Know locations of head and neck lymph nodes, and their
drainage pattern;
· Know the fontanels (p. 256) and their usual ages at closure;
· Know that the thyroid gland can be slightly enlarged during
pregnancy;
· Know information to obtain for headaches, as well as the
precipitating factors for migraines (p. 257 and again on 270);
· Know the terms: normocephalic, microcephalic,
macrocephalic, hydrocephalic, acromegaly, and
lymphadenopathy;
· Know that you should use a gentle, circular motion of the
fingerpads to palpate lymph nodes; it is best to use both hands,
comparing the findings of one side to the other side;
· Know the characteristics of cancerous nodes as well as those
of Virchow’s node- which is a type of enlarged supraclavicular
node (p. 262);
· Know the posterior approach for assessing the thyroid gland,
and that you usually cannot palpate the normal adult thyroid;

5. the thyroid is also auscultated for a bruit- a whooshing type
noise heard with turbulent blood flow (remember that when
assessing a dialysis fistula, we ausculate for a bruit, and palpate
for a thrill- similar to feeling a cat purr; in this case, a bruit and
thrill are considered signs of normal functioning of the fistula.
In most other cases, a bruit or thrill are abnormal findings.);
· Know that the infant’s head circumference is measured at each
well visit until the age of two years, and that at birth the head
circumference is larger than the chest; these are equal by age
two years, and after that, the chest is greater than the head;
· Know, with the newborn, caput succedaneum (p. 264) and
cephalhematoma (p. 265); both normally resolve without need
for treatment;
· Know the information on bulging, tense, or pulsating
fontanels, associated with increased intracranial pressure, and
sunken, depressed fontanels, associated with dehydration or
malnutrition; assessing the fontanels is one way of assessing
fluid status of the newborn and infant (p. 266);
· Know the tonic neck reflex (p. 266), and when it normally
disappears;
· Know the main differences between types of headaches on p.
270;
· For abnormal conditions, know: hydrocephalus, Paget’s
disease (osteitis deformans), acromegaly, torticollis, goiter, the
features of fetal alcohol syndrome, Down syndrome, allergic
salute and crease, Parkinson and Cushing syndromes;
· For hyperthyroidism, know the basic features including goiter
and exophthalmos, as well as those of
hypothyroidism/myxedema; understand the main differences
between Bell’s palsy and stroke/CVA (cerebrovascular
accident); know the term cachectic, and scleroderma;
Finally, with this unit you can begin to use Evolve Nursing
Video Skills DVD. Open it, agree to the statement at the
beginning, then go to Overview; from here you can go to several
areas; try Procedure Video: this gives you the choices of the
various systems to assess. For this unit, it would be Skin, Hair

6. & Nails, as well as Head, Neck & Lymphatics. In any of these
you can click on Procedure Video to get a list of the various
things to assess in this area. By clicking on one, you are shown
an assessment of that area, with important information to know.
Also try going under NCLEX Review for sample questions
covering this area; you are given the answers and rationales, so
these are good to review. You can also try the Critical Thinking
case studies; these may be helpful for you.
5
B344: Comprehensive Health Assessment
Week 1/Module 1 Student Notes
Module 1 covers Jarvis chapters 1 – 9. The assigned chapters
are 3, 4, 5, 8 & 9; these notes will concentrate on the chapters
not assigned. Even though some chapters are not assigned, I
may refer you to specific information in them in these student
notes.
Chapter 1: Evidence-Based Assessment
· Understand subjective vs. objective data (p. 2)
· Review first-level, second-level, and third-level priority
problems (p. 5-6)
· In this text, they refer to first-level priority problems as ‘ABC
plus V’, referring to Airway, Breathing, Cardiac/Circulation,
and Vital sign concerns (high fever, high or low BP, etc.)
· Know the 4 types of databases (p. 7-8):
· Complete/Total Health Database: this is made up of the
complete health history (which you will be performing for your
first assignment) and a full physical examination
· Focused, or Problem-centered Database: a limited database
targeting a specific problem

7. · Follow-up Database: the evaluation of a specific problem,
used for short-term or chronic problems
· Emergency Database: the rapid collection of data, often done
while lifesaving measures are being implemented, such as those
obtained in the ED
Chapter 2: Cultural Competence/Cultural Care
· You can review this chapter as desired; it will not be tested
over
· HOWEVER: Nurses should be asking the client if there are
cultural, spiritual, or religious values they have so the nurse can
provide optimum care!!!
Chapter 3: The Interview
This is an assigned chapter, and one you will be using for your
complete health history, so do read it. I will draw your attention
to a few things:
· Note the material on empathy and active listening (p. 30)
· Review external factors: the physical setting (privacy,
interruptions), equal-status seating, dress, and note-taking (p.
30-31)
· Review open-ended vs. closed or direct questions (p. 32-33)
· Review the 9 types of verbal responses (facilitation, silence,
reflection, empathy, clarification, confrontation, interpretation,
explanation, and summary) (p. 33-34)
· Note that part of the complete health history assignment will
include a self-assessment, where you will evaluate things like
the interview environment, and your use of questions and verbal
responses

8. · Do note the 10 traps of interviewing (p. 35-36); these also
apply to general patient care, and so are good to keep in mind
· Review the nonverbal skills (appearance, posture, etc.)
· For the section on Developmental Competence (starting on p.
37), quickly read through the sections on children- we will refer
back to this information later when doing the pediatric
developmental/nutritional assessment. Do pay attention to the
sections on the adolescent and older adult
Chapter 4: Complete Health History
The complete health history collects subjective data; to this is
added the objective data from the physical assessment and
lab/diagnostic studies to form the complete health database.
Note that while basic personal information is obtained for actual
institutional use (person’s name, address, date of birth etc.) for
your assigned health history you should be careful to omit any
of the specific HIPAA patient identifiers listed in the course
syllabus. Know the main parts of the complete health history:
· Reason for Seeking Care; note that this was formerly called
the ‘chief complaint’, but language is changing; this avoids
calling the patient a complainer, and includes wellness goals or
‘routine maintenance’ types of healthcare visits
· Present History/History of Present Illness: if well, this is a
general statement of their state of health; if ill, it is the reason
for seeking care, and all the pertinent information about the
problem (onset, symptoms, location, etc.)
· Past Health: including childhood illnesses, accidents/injuries,
hospitalizations, operations, obstetrical history, immunizations,
last exam dates, allergies and current medications
· Family History: this section pertains mainly to blood relatives,
to identify those disorders that may run in the family that the

9. subject may be at risk for; the text explains a family genogram,
which you will not need to make for your health history
assignment, and do not need to know in any detail. Finally, the
person is asked about those living in their household
(spouse/children) related to factors that may put them at risk for
illness, such as chronic exposure to smoke
· Culture/Genetics: this section is relative mainly to those who
are recent immigrants to this country
· Review of Systems: this goes through each main body system
to identify any past or current problems
· Functional Assessment: this section centers around self-care
abilities, and will be examined in depth when you do the
functional assessment of the older adult assignment; it includes
the areas of self-esteem, activity/exercise, sleep/rest,
nutrition/elimination, relationships/resources, spiritual
resources, stress and coping, personal habits, alcohol, illicit
drugs, environmental hazards, intimate partner violence and
occupational health
· Perception of Health: this part identifies concepts of health
that are important for the person, and their personal goals for
health
Following this section, the text covers the health history for
children, including developmental and nutritional information
which you will use for your second assignment. Read through
the section on adolescents, noting that the youth should be
interviewed alone; questions usually move from less personal
ones to more sensitive issues; see the HEEADSSS questions on
p. 65. Finally, the health history of the older adult is covered;
read through this material, which we will use for the third
assignment.
Chapter 5: Mental Status Assessment

10. Note the definitions of some common terms given on p. 72. The
mental status is actually assessed throughout the health history
process, as well as during a specific mental status assessment.
Mental status includes both emotional and cognitive
functioning; the main components are referred to as A, B, C,
and T: Appearance, Behavior, Cognition, and Thought
processes. Related to orientation, note that orientation is
usually lost in the order of time, then place, and finally to
person. Note the differences between delirium and dementia
given on p. 80. Also note the various levels of consciousness
given on p. 83, and the basic speech disorders on p. 84:
dysphonia, dysarthria and aphasia. You are not responsible for
knowing the different types of aphasia. Do need to know the
basics of schizophrenia, delirium, dementia and amnestic
disorders (p. 87-88), mood disorders (p. 89), and anxiety
disorders (p. 90-91).
Chapter 6: Substance Use Assessment
This chapter focuses on the use of alcohol and illicit drugs.
Note that illicit drugs include prescription drugs taken for non-
medical reasons. Also note that the fastest growing drug
problem in the US is abuse of prescription drugs, specifically
oxycodone, hydrocodone and methadone. Note the definitions of
a standard drink on p. 94; you will not be tested on things like
this though. Also note the definitions of ‘at-risk drinking’ for
men and women on p. 96. Finally, note the definitions of
intoxication, abuse, dependence, tolerance and withdrawal on p.
100.
Chapter 7: Domestic Violence Assessment
This chapter covers intimate partner abuse, child abuse and
elder abuse, which we all need to be watchful for. Note the
definitions of child neglect, and physical, sexual and emotional
abuse on p. 103. Read through the risk factors that may
contribute to child abuse on p. 105. Also note that to report
abuse; you do not need to have proof of abuse or neglect, only

11. reasonable cause to suspect that it may have occurred. Various
types of questionnaires are given, which you are not responsible
for knowing as each institution usually has its own method of
dealing with these issues. Just know they are here should you
need one in the future. The American Nurses Association
(ANA) has asked nursing to inquire if their client served is
being subjected to any type of abuse, now or in the past. The
ANA wants us to ask this upon admittance, at every change of
level of care (ICU to TCU to floor; at every life changing event:
divorce, marriage, separation, etc.).
Chapter 8: Assessment Techniques and the Clinical Setting
This chapter is included in your reading assignment, but I will
point out a few things here. The 4 basic techniques used are
inspection, palpation, percussion and auscultation, which are
usually performed in that order. One notable exception will be
when we get to the abdominal assessment, where we use
auscultation prior to palpation and percussion. Inspection
always comes first, assessing things like color and symmetry.
Palpation is used to assess texture, temperature, moisture, organ
location, swelling, vibration or pulsation, rigidity or spasticity,
crepitation, presence of lumps or masses, and for tenderness or
pain. Note the following:
· Fingertips are best for fine tactile discrimination, such as
texture, pulsations or swellings
· The dorsal surface of fingers and hand are best for
determining temperature
· The base of the fingers (metacarpophalangeal joints) or ulnar
surface of the hands is best for detecting vibration
· Light palpation should be used first, followed by deeper
palpation as needed
Percussion is undoubtedly the least used technique by

12. clinicians, which is unfortunate, because with practice, this
technique provides valuable information. You will be
responsible for knowing the basic percussion tones: resonant,
hyperresonant, tympany, dull and flat (see p. 117). Auscultation
is simply listening, which we most often do with the help of a
stethoscope. Note that to be most effective, the stethoscope
tubing should be short (14-18 inches long). Note that the
diaphragm should be applied firmly, and is used for high-
pitched sounds, while the bell is held lightly against the skin,
and is used for low-pitched sounds such as heart murmurs.
Then, something I continually have to remind my clinical
students of: never listen through a gown or other clothing!
Listen directly over the skin to obtain trustworthy results. Know
basically what an otoscope and ophthalmoscope are; you do not
need to know the specifics about the ophthalmoscope, such as
what the various settings are used for. Review the standard
precautions for use with all patients on p. 121. Finally, read
through assessment differences based on developmental level.
Chapter 9: General Survey, Measurement, Vital Signs
This is the final chapter of this module, and is included in your
reading assignment. The general survey is an overview of the
person as a whole, and includes evaluation of their physical
appearance, body structure, mobility and behavior.
Measurement includes weight, height and body mass index,
which is used to determine obesity vs. malnutrition. See p. 130
for the classifications of BMI. Note that the BMI overestimates
body fat in persons who are very muscular (muscle tissue
weighs more than fat tissue) and underestimates body fat in
older adults who have lost muscle mass. You are not responsible
for memorizing the formulas for BMI (p. 132).
For the vital signs, note that the pulse should be counted for 30
seconds, then multiple by two if the rate is regular; if irregular,
count for a full minute. Know the terms bradycardia and
tachycardia, and the scale used for describing the force of a
pulse: 3+, 2+, 1+ and 0 (p. 135). As with the pulse rate, count

13. respirations also for 30 seconds or for a full minute if there is
an abnormality. For blood pressure, know the terms systolic,
diastolic, pulse pressure, mean arterial pressure (MAP), and
cardiac output. Note that a blood pressure cuff that is too
narrow produces a blood pressure that is falsely high. Note the
Korotkoff sounds on p. 139, and that the blood pressure is
measured from sound I to sound V. Also note the information on
the auscultatory gap, and how to avoid this. Read through
orthostatic or postural vital signs: pulse and blood pressure
obtained while supine, sitting then standing. Note the
information on the pulse oximeter, which, I believe, will rapidly
become another of the standard vital signs. It is quick, easy and
accessible to most nurses. Likewise, Dopplers are readily
available in most clinical settings to aid in the assessment of
peripheral pulse sites.
For the section on abnormal findings, note dwarfism vs.
gigantism, acromegaly, anorexia nervosa, and obesity:
endogenous vs. exogenous. Exogenous obesity is caused by
external factors: overeating and inadequate exercise, while
endogenous is due to internal factors such as Cushing syndrome,
a metabolic disorder. Finally, know hypotension vs.
hypertension (p. 156); for hypotension, note the definition, and
when it occurs. For hypertension, know the levels of normal,
prehypertension, Stage I and Stage II hypertension, as well as
the major risk factors. Finally, know the lifestyle modifications
for those with hypertension or prehypertension (p. 157).
Running head: APA GUIDELINES
1
APA GUIDELINES
2
1) Never assume the reader knows what abbreviation represents.
Always type the word first with abbreviations in (), then you
may use the abbreviation throughout the paper. Measles,

14. mumps, and rubella (MMR).
2) Header will be used in every APA paper, no exceptions. 1st
page header is different from all other pages.
3) Numerals <10 are spelled out unless it used in a date, height,
weight, etc.
4) Introduction does NOT warrant header. (Page 27, Section
2.05)
5) First page is cover page with the header at top of page with
page number. Title of the paper, your name, and university is in
the upper first half of the paper. NOTHING else is on the cover
page!
6) Second page should be the start of your paper. The title is
always centered on the second page unless an abstract is
required. THERE IS NO abstract required for this course. With
that being said, the second page should have the title of your
paper, then the introduction. Remember do NOT include
INTRODUCTION at top of page as APA states the intro does
not warrant a title!
7) Headers are used in APA. First page should have this in the
header: Running head: TITLE OF PAPER (no more than 50
characters including spaces) flush left with page number flush
right.
8) The header for all pages after page 1: TITLE OF PAPER
flush left with page number flush right.
9) First line of every paragraph is indented.
10) First level headers are bolded, centered. No lines
underneath, colons, bullets.
11) Second level headers are bolded, flush left. No lines
underneath, colons, bullets.
12) Third level headers are bolded, flush left with indent and

15. period at end. Comments start immediately after period.
13) Double space, Times Roman New Font, 12 inch pica, one
inch margins all the way around.
14) To remove the extra space that seems to appear in some
papers (especially after a paragraph), highlight the text, click on
review, line spacing, and remove the line after the paragraph
(you may also need to remove the line before the paragraph.
15) If the requirement is for a six page paper, APA format: the
first page is the title page, pages two, three, four, and five are
filled with the text (evidenced based research), and page six is
the reference page. Make sure you adhere to the required page
limit.
For those of you that this is your first class that requires APA
…keep your papers, correct the errors, and use your papers as a
guide for the next paper.
The Owl at Purdue is an excellent resource of APA formatting.
Your writing center on your campus is an EXCELLENT
resource for APA formatting.
Running head: ADULT HEALTH HISTORY
1
ADULT HEALTH HISTORY
9
This is how the Running head should appear on page 1, it is
different on all other pages – please review. Please remember
the running head after the colon cannot be more than 50
characters, including spaces. Your title in the running head
may be shortened due to this.
Adult Health History
First and Last Name

16. Indiana University Southeast
Adult
Health History
This
documentation is a comprehensive health history of TJ, a 45
year old male who lives
in Indiana. TJ has been married for 25 years. He and his wife
have two daughters who are 21
and 22. The oldest daughter has a masters in elementary
education and teaches in the Greater
Clark school corporation. She has been married for two
years and she and her husband are
expecting their first child in May. The youngest daughter is
finishing her senior year of nursing
school at the University of Louisville. TJ denied having any
cultural, religious or spiritual values
that would inhibit him from participating in this interview. TJ
denies any exposure to domestic
partner violence or sexual abuse. The interview took place in
TJ’s living room. The setting was
very nice, quiet, comfortable, and free from distractions.
Present Health/History of Present Problem(s)
TJ reports no present health issues.
.
Past Health
Childhood illnesses
TJ denies having measles, mumps, or rubella (MMR

17. ), and pertussis. He did report
having chicken pox at age six. Many episodes of strep throat
(denies knowledge of rheumatic
fever), tonsillectomy at age nine.
Accidents or injuries
Bike wreck in third grade, broken collar bone and pulled growth
center from humerous.
Laid in traction for three weeks at hospital. Doctor was not sure
if damage to growth plate would
cause long term issues. Arm grew at normal rate and size, no
problems.
Serious or chronic illnesses
Denies any history of serious or chronic illnesses.
Hospitalizations
Only hospitalization was in 1979 when shoulder was broken as
documented under
“Accidents and injuries”. No long term complications.
Operations
Surgery to repair collar bone and growth center in 1979. No
long term complications
Obstetrical history
Does not apply.
Immunizations
Has documented history of the following vaccines: MMR, polio,
diphtheria-tetanus-and
pertussis (Dtap), and varicella. Denies having hepatitis A or B,
meningococcal vaccine, human

18. papilloma virus, haemophilus influenza type B, pneumococcal
vaccine, and influenza as a child.
Has received influenza vaccine every October for past 20 years.
Hepatitis B was administered
February of 1991. The last tetanus immunization was in 2014.
The last tuberculosis skin test was
January 13, 2016. TJ advised he will be receiving Dtap before
the birth of their first grandchild
in May.
Last examination dates
Has dental checkup twice a year along with oral cancer
screening. Last physical was in
2015. Denies hypertension, hyperlipidemia, any occult blood,
or any issues. Denies issues with
hearing loss. Has never had an electrocardiogram or chest x-
ray. Performs self testicular exam
on the 20th day of each month. This is a male client so there is
history of mammogram or pap
smear. Vision was tested in 2015, no issues found.
Allergies
Denies any drug, food, environmental, contact, or latex
allergies.
Current medications
Occasionally will take 400 milligrams (mg) of ibuprofen or 650
mg of acetaminophen
for headache (once every couple of months). Denies any other
prescribed or street drugs. No
herbal remedies.
Family History
Maternal grandmother died from breast cancer at the age of 70.

19. Maternal grandfather
died from a heart attack at the age 52. Paternal grandmother
died in her sleep at the age of 92.
No history of any disease process. Paternal grandfather died in
his sleep at the age of 94. No
history of any disease process. Mother is 69 years old and has
history of hypertension and supra
ventricular tachycardia. This is controlled with metoprolol and
is taken each night before bed.
TJ’s father is 71 years old and has no history of any disease
process. There is no family history
of stroke, diabetes, obesity, cancer, arthritis, allergies, alcohol
or drug addiction, mental illness,
seizure disorder, kidney disease or tuberculosis. Denies any
long term exposure to tobacco
smoke, communicable diseases, or any other environmental
exposures.
Review of Systems
General constitution
Advises general health is good. TJ rarely gets a cold, fever, or
sore throat.
Skin, hair & nails
Denies any issues with dry or oily skin or hair. States nails are
not brittle.
Head, neck

20. Denies any issues with head or neck.
Eyes, ears, nose, and throat (EENT)
Denies any issues with EENT
Chest/lungs, and breast (for women)
No issues with chest or lungs.
Heart/blood vessels, and peripheral vasculature
No problems with heart/blood or peripheral vascular systems
Gastrointestinal (GI)
No issues with GI system.
Endocrine
Denies any issues with thyroid or diabetes.
Female (menses, pregnancies)
Does not apply.
Genitourinary
Denies any issues.
Musculoskeletal

21. Denies any issues.
Neurologic
Denies any issues.
Functional, Personal & Social History
Activity/exercise
Employed at Ford Motor Plant four days a week, twelve hours a
day. Returns home, has
dinner, may take a walk with spouse. Have a pool they get in
every evening during the summer
months. No mobility issues.
Sleep/rest
No difficulty sleeping. Goes to bed at 11:30 p.m. and gets up at
4:30 a.m. Daytime
napping may occur on a Sunday afternoon for an hour or two.
Nutrition
Denies any unintended weight loss or gain. Eats all types of
food and includes a variety
of vegetables, fruits, and meat. Denies any food allergies. TJ
states he drinks two cups of coffee
each morning and has six to eight glasses of water a day. His
treat in the afternoon is one coke.
There are no foods forbidden due to cultural or religious values.
He and his wife both participate
in cooking dinner and there is no problem obtaining groceries or
preparing them.
Relationships/social support
TJ and his wife enjoy going to church on Sunday mornings.
They will have dinner with
all of the siblings the first Sunday of every month. He and his
wife have a couple of friends they

22. attend the high school basketball games with and go out to eat
dinner with. They have family
dinner every night, and attempt to have dinner at least two
Sundays each month with both
daughters and son-in-law. Thanksgiving is alternated each year.
TJ’s sister hosts one year, and
TJ hosts the next year. Christmas Eve is spent with both
daughters and son-in-law. Christmas
day is calm with holiday movies. Family is very important to
both TJ and his wife. Their faith is
very important to them and TJ said he does not know what he
would do if he did not believe in
Jesus Christ.
Stress and coping
TJ states he really has no stress in his life other than awaiting
the arrival of their first
grandchild. When the girls were younger and would cause a
little chaos, he normally would go
for a walk, pray, and have a beer. If he needs to de-stress in the
summer months, he goes for a
swim their pool. He commented he is very thankful his girls did
not get in much trouble.
Personal habits
TJ denies any tobacco use or recreational drugs. He has five or
six beers a month.
Safety issues
TJ lives in a gated community and feels safe in his home and
neighborhood. He
advised he wears his seatbelt every time he is in a car. He uses
sunscreen when outside.

23. Financial concerns
TJ has exceptional healthcare, can afford his medication (tier
level), and says all
preventative care is covered at 100% .
Conclusion
TJ stated he could not think of anything of importance that he
omitted from our
conversation. He felt he had been very open and forthcoming
when answering the questions.
This writer was very appreciative TJ was open and welcoming
of the interview.
Self-Evaluation
Open ended question were utilized during this interview. The
living room was spacious
and quiet. There were distractions. Clarification and silence
were used during the interview.
Silence is an obstacle to get through without squirming and
wanting to talk. This writer did not
fall into any of the ten traps of interviewing. The question
about sexual assault and domestic
violence was added to the questions for this interview. Griffin
& Kross (2002) and The Joint
Commission on Accreditation Healthcare Accreditation
(JCAHO) (2010) have encouraged all
nurses to ask the client “Are you now or have you ever been a
victim of sexual assault and/or
domestic violence”. JCAHO (2010) suggests this should be
done at every level of care (moving

24. from intensive care unit(ICU) to the floor, from the emergency
room to the floor, when there is a
divorce, change of significant partner, or any life event). The
client may not disclose the first
time asked but may eventually feel they are in a safe
environment to disclose and ask for help.
References
Griffin, M., & Koss, M. (January 31, 2002). Clinical screening
and intervention in cases of
partner violence. Online Journal of Issues in Nursing,(7)1.
Retrieved from
www.nursing.world.org.Main
MenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Volume72002/No1Jan2002/ClinicalScreeninga
ndPartnerViolence.aspx
Joint Commission on Accreditation of Healthcare
Organizations. (2010). Preventing violence in
the healthcare setting. Retrieved from
www.jointcommission.org/assets/1/18/sea_45.pdf
Jarvis, C. (2012). Physical examination and health assessment:
Text and physical examination
and health assessment online video series (6th ed.).
Philadelphia, PA: Elsevier, Saunders
Wooldridge, M.B., & Shapka, J. (2012). Playing with
technology: Mother-toddler interaction
scores lower during play with electronic toys. Journal of
Applied Developmental
Psychology, 33(5), 211-218.
http://dx.doi.org/10.1016/j.appdev.2012.05.005
INDIANA UNIVERSITY SCHOOL OF NURSING
B344 Comprehensive Health History

25. Adult Health History Assignment Grading Rubric
Complete Adult Health History
Topics
Exceeds Standard (points)
Meets Standard
(points)
Below Standard (points)
Comments
Introductory Paragraph*
5
4
3
Present Health/History of Present Problem(s)*
5
4
3
Past Health*
15
12
10
Family History*
15
12
10
Review of Systems*
15
12
10
Functional, personal and social history*
15

26. 12
10
Conclusion*
5
4
3
Self-Evaluation of Interviewing Techniques
Reflection*
15
12
10
Writing Guidelines
Writing
10
9
8
Total Points
*See assignment description for full discussion of expected
content.
Exceeds Standard: Essential content fully and thoroughly
developed (A or B work); Meets Standard (C work): Contains
essential content; Below Standard: Essential content
missing/incomplete (< C work)
�Title, Author, & University in upper half of title page

27. �Title of Paper is always first.
�Indent each paragraph. A paragraph is at three sentences.
The “introduction” does NOT warrant a header.
�All numerals <10 are spelled out There are exceptions, please
see OWL at Purdue or APA 6th Edition
�First level headers are bolded and centered.
�Second level headers are flush left and bolded
�Always spell the word out first with abbreviation in ( ). The
next time mentioned in text, the abbreviation may be used.
�If you have references, the last page will be the reference
page. Listed in alphabetical order. Remember that each
reference must be cited in text.
�Example of Journal with Volume and Issue
�Example of journal
�Not used in this document. Example of book.

28. �This was not used in this document. Example of reference
with DOI number.
�The rubric is required to be attached as the last page of the
document