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E-Folio: Essential IX
Margaret Anyiam
Frostburg State University

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E-Folio: Comprehensive Health Assessment and Physical Examination
Baccalaureates Essential IX describes the general nursing skills and the procedures an
individual is expected to attain at the end of the program. It basically incorporates communities,
groups, families and individuals nursing care (The American Association of Colleges of
Nursing, 2008). This Essential summarizes all the other modules, and is focused on the
integration of acquired knowledge and skills into the nursing practice. Besides the acquisition of
the core knowledge in the field such as health promotion and disease management, it seeks to
establish ethical values that are necessary while handling patients and collaborating with other
practitioners. It emphasizes the importance of other skills such as communication and psycho
motor skills in the nursing practice, so as to enhance efficiency. Communication skills play a big
role in the nursing practice, because they enhance proper understanding between nurses and
patients, which in turn facilitates efficiency in the practice.
By gaining valuable knowledge, appropriate skills and the right attitude, graduates are
well equipped to offer care to all demographics across life span. This includes those who require
special attention, such as those with high prevalence of chronic diseases, mental disorders, and
the older adult population. These skills are particularly useful now that there is increased
diversity in the population, in terms of its spirituality, culture, ethnicity and sex. This variety of
heath care problems due to the increased globalization, require versatility from care givers, who
may be required to work in multicultural environments. Globalization has led to a steady
increase in health care related problems; hence there is need for nurses and other professionals in
the nursing field to diversify their operations.
The knowledge and skills from the baccalaureate training will help nursing professionals
in maintaining strategic positions in the industry, for long term careers in a constantly changing
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health care environment. This is necessitated by the increased prevalence of chronic diseases,
and a rise of the older adult population, which has necessitated more health care interventions to
prolong life. Health care knowledge is evolving rapidly and slowly getting complicated. This
requires constant lifelong learning and continuous self-evaluation graduates. This is to enable
them to communicate with patients and disseminate this knowledge from a more informed point.
This greatly improves the care partnership established between nurses, patients and their
My complete physical and health assessment of a client with respiratory problem relates
to essential IX in many ways. I conducted the health assessment, taking a look at the physical
condition of the patient, history of the present illness, the patients overall medical history,
family history and spiritual affiliation among other factors. According to the American
Association of Colleges of Nursing (2008), a well trained baccalaureate graduate in one way or
the other, should be in a position to conduct comprehensive assessments of patient health, using
culturally and developmentally appropriate approaches (The American Association of Colleges
of Nursing, 2008).
In the assignment, it was important to respect the patients wishes as stipulated by
objective 5 of this essential, that requires care givers to deliver compassionate, patient-centered
and evidence based care that respects patient and family preferences (The American Association
of Colleges of Nursing, 2008). For example, the patient requested that the health care giver
attending to them be a female. When giving patient care, patients/families spiritual and personal
beliefs should be respected.

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When attending to the patient, I employed tools such as EcholsArmstrong Cultural
Assessment Tools (EACAT) for cultural assessment, and FICA- Faith, Importance/Influence,
Community, and Address for spiritual evaluation to obtain a complete view of the patient. A look
at the patients history of the present illness and the general medical history obtained using the
therapeutic interviewing techniques was important in understanding the relationship between
nutrition, lifestyle changes and past diagnoses. It was also helpful in monitoring the effectiveness
of the chosen treatment. This information was very helpful in this case, as it revealed that the
patient had been diagnosed with hypertension a year ago, and the problem they were
experiencing was a result of missing medication for two weeks. It also exposed the effects of
other social factors such as marriage problems, financial constraints and drinking of alcohol on
the patients health.
I was able to establish that the patient could converse in fluent English without the help
of a translator. This directly related to the essentials fourth objective, which strictly requires
effective communication by nurses (The American Association of Colleges of Nursing, 2008).
This is valuable when providing patient teaching or when using interviewing techniques to
gather information. Through looking at the patients dietary history and the physical examination
of the patient, it was possible to establish that the patient is having inadequate nutrients in her
diet. The patients Body Mass Index was high as a result of the frequent intake of fast foods that
contain excess fats, sugars and salt. With this knowledge, I prepared a nursing diagnosis with
accompanying goals and interventions (Ralph & Taylor, 2005). Besides, I formulated another
diagnosis, accompanied with an intervention to tackle the patients non compliance to treatment.
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Appropriate patient teaching and intervention influenced by their spirituality, age, race, lifestyle
and cultural beliefs is necessary to foster the patients engagement in their care.
By outlining the above, I have come to understand how spiritual and cultural beliefs
impact healthcare choices. In this particular study, the patient integrated spiritual care into their
daily life. Further, with the completion of this task, I have demonstrated the integration of critical
thinking, clinical judgment and diagnostic reasoning in carrying out a comprehensive health
assessment. Through this nursing process, I have implemented evidence based interventions to
manage acute and severe conditions facing this patient. I have been able to evaluate the
efficiency of setting individualized care plans and interventions, targeted at achieving better
patients health outcome
Through this project, I assessed my skills in both clinical and laboratory background. I
gained scope of the practice, used basic nursing principles of basic care in planning and
implementing care, and appreciated the role of baccalaureate graduates as direct nurses and
caregivers. This task enabled me to apply evidence-based standards to screen, immunize and
promote health as required by this essential. I achieved the course objective to promote healthy
individuals, families and communities, by organizing health care needs of different populations
and cultures across the life spans. The patient is the number one focus for us caregivers (Black,
2013). After successfully completing this assignment, I have satisfied the requirements of this
essential. Based on collected evidence, I have been able to provide patient-focused care, which
respects the patients preferences, while utilizing the knowledge acquired in nursing. Through
this, I have effectively demonstrated strict professionalism in the career, and have been able to
create an environment for safe care, that makes patient outcomes to be of high quality (The
American Association of Colleges of Nursing, 2008). This promotes better patient health, and
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ensures that the care givers continually develop their skills, to be able to proficiently work as
members of a professional team.
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Black, B. P. (2013). Professional Nursing: Concepts & Challenges. Amsterdam: Elsevier Health
Ralph, S. S., & Taylor, C. M. (2005). Nursing Diagnosis Reference Manual. Philadelphia:
Lippincott Williams & Wilkins.
The American Association of Colleges of Nursing. (2008). The Essentials of Baccalaureate
Education for Professional Nursing. Retrieved from

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Comprehensive Health Assessment and Physical Examination
Points possible Criteria
2 Chief Complaint (CC) noted
I have a severe headache that is not cured by painkillers
and for a day now, I feel breathless
3 History of present illness
The patient was diagnosed with hypertension 12 months
ago. The patient has been on medication since then. For the
last two weeks she did not take medication as she did not
have time to go for a refill. She wants a refill of her
medication. She has been having severe headaches for two
days. She took painkillers but the headache was still
persisting. She has also experienced breathlessness for one
day. The patient decided to take her blood pressure at home
and it was 175/100. The patient cannot adhere to the
recommended nutritional regimen as she is too busy.
5 Past medical history
Hypertension in pregnancy 1995
Pre-eclampsia 2000
Head injury 2010
Hypertension 2012.
As a child, the patient recalls a history of malaria, measles
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and typhoid. The patient recalls an episode of blood
transfusion following the malaria infection.
Past Surgical history
Caesarean section 1995.
Emergency caesarean section 2000.
5 Allergies
Sulfur allergies (rash)
The patient denies allergies to any environmental agent or
5 Carvedilol 6.25mg BD
Enalapril 5mg BD
She has used both the two drugs for a year, since she was
diagnosed with hypertension to date.
5 Family health history
The patient has two children; a son 13years old and a
daughter 18years old. They are both in good health
although she suspects that her daughter is taking hard
drugs. Her father has hypertension and diabetes that is
related to old age. Her mother also has hypertension and is
now paralyzed following a cerebrovascular accident. She is
the third born in a family of four. She has two brothers and
one sister. Her brother was recently diagnosed with
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diabetes at 40years.
5 Social history
The patient smoked tobacco for two years but quit after
being diagnosed with hypertension. She drinks alcohol, a
minimum of two glasses a day. She denied use of any hard
drugs. She has a history of domestic violence that resulted
in her head injury in 2010. The couple is currently seeing a
marriage counselor. She has had one sexual partner, the
husband for the last 15years. She was using combined oral
contraceptives as a birth control but stopped and started
using condoms after being told of the risks of hormonal
contraceptives on a hypertensive patient. The use of
condoms is contributing to the marital problems she has
with her husband. She has a degree in sales and marketing
and is currently employed as a sales representative. She
complains that there are too many demands from her
extended family back in Kenya and she has to work extra
hours to pay bills and send them money. She feels
inadequate in her role as a mother and her two teenagers
are troublesome.
5 Spiritual assessment using FICA tool
Faith/Belief: The patient is Muslim.
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Importance: She said that the mosque is the only source of
consolation as she has a problematic marriage and financial
Community: She belongs to a spiritual community near her
home she goes every Friday for prayers.
Address: She requested that the health team recognize that
her spiritual beliefs are important in maintaining her health
5 Cultural assessment using EcholsArmstrong Cultural
Assessment Tools (EACAT)
Ethnic group affiliation and racial boundaries: The patient
has lived in the United States for 20years. She is African.
She was born in Kenya and moved to the United States
after winning the United States green card lottery.
Major Beliefs and values: Health care decisions in her
family are made by the husband. Her community does not
allow her body parts to be seen by people of the opposite
sex. She prefers that the health care provider attending to
her should be of the same sex with.
Language barrier and communication styles: She said that
she is able to converse well in English and does not require
an interpreter.
The role of the family spousal relationship and parenting
styles: The family is inclusive of the extended family. Her
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community requires that a woman should have as many
children as possible and they are putting pressure on her to
have more children. Her previous pregnancies have been
5 Nutritional assessment
The patient is 84kg but does not recall her height. The
patient does not follow a particular diet. She takes fast food
every day at lunchtime. She has enough resources to buy
food but does not have time to prepare meals. She takes
lunch with her workmates and dinner with her family. The
patient had a cup of coffee for breakfast. The previous
night she ordered pizza for dinner.
5 Health maintenance
She cannot have enough sleep because she is expected to
work overtime to cater for her familys needs. She does not
exercise as she does not have time though she has been
considering creating time for it as she was advised to
exercise following the diagnosis of hypertension. The only
way she manages stress is by spiritual guidance.
20 Review of Systems.
Eyes: The patient says she can see clearly. She has never
had an ophthalmic review. She denies any pain, discharge
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or blurred vision.
Ears: The patient denies any hearing difficulty, pain or
discharge from the ears.
Nose and Sinuses: The patient has had a running nose on
several occasions but no change in the sense of smell. She
has experienced epistaxis on several occasions which she
was treated and told it can be controlled by controlling her
blood pressure.
Mouth: The patient had a dental checkup last month. She
denies bad breath or toothache. She brushes her teeth OD
and flosses frequently but not on specific intervals.
Throat and neck: The patient said she had a sore throat
recently that has since healed. She denied masses or change
in voice
Breast: Patient denied history of masses and discharge pain
as well as change in color or change in size
Respiratory: Patient has experienced chest pain and
breathlessness for a day. Patient denies history of any
chronic respiratory condition
Cardiovascular and peripheral vasculature: Patient denies
pallor koilonychias or cyanosis.
Gastrointestinal: Has had constipation and flatulence in the
past. Denies abdominal pain, abdominal distension or
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change in consistency and color of fecal matter
Musculoskeletal: Denies muscle pain, joint pain or
Neurological: Patient complained of feeling dizzy often.
Denies change in level of concentration,
Psychological: Patient has contemplated suicide because of
stress from the family; she also has problems going to
sleep. She accepts that she is depressed.
Urinary: Increase in the amount of urine. Denies change in
consistency, change in color or pain when urinating.
Lymph nodes: Denies enlarged lymph nodes or edema
Hematological: pt had anemia as a child, denies hemophilia
or sickle cell anemia.
20 Physical examination
1. Constitutional
African female who looks breathless and in distress. She is
also sweating
Temperature:36.9 degree Celsius
Pulse: 100beats/ minute
Respiration: 30 respirations per minute (irregular)
Blood Pressure
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168/100mmHg (Left arm sitting)
170/110mmHg (Right arm sitting)
160/95mmHg (Left arm supine)
2. Eyes
Healed wound that looked like a black eye
Bilaterally symmetrical. Both pupils responsive to light. No
sign of discharge or inflammation on the lachrymal
apparatus. Visual Acuity 20/20 for both eyes. No
3. ENT/mouth
No halitosis, decay or dental appliances or dry mucous
membrane. No tonsillitis. Teeth are well aligned. 28teeth in
good condition. On palpation no signs of masses around the
neck. No lymphadenopathy.
4. Respiratory
The patient has difficulty in breathing. Chest expansion
bilaterally symmetrical. Anteroposterior diameter is twice
the transverse diameter. Coastal angle is less than 90
degrees. No use of abdominal muscles or the
sternocleidomastoid muscle.
On percussion, resonance was normal.
5. Cardiovascular
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Apical pulse 100beats per minute. Jugular vein not
distended. Blood pressure of 170/110 right hand sitting.
First and Second heart sound normal. There is a fourth
heart sound.
6. Gastrointestinal
No abdominal distension. No visible veins. Bowel sounds
present in all four abdominal quadrants. No spleen
enlargement. A surgical scar on the abdomen. The liver is
8cm in diameter. No renal artery bruits.
7. Hematologic/lymphatic
No pallor or jaundice. Capillary refill of less than 3seconds.
No edema. No swollen lymph nodes
8. Musculoskeletal
The patient has normal gait. No signs of peripheral edema.
No inflammation of bones or joints. Muscles are well
developed. Range of movement normal for all joints. No
muscle weakness.
9. Psychiatric
The patient looks sad and distracted. She is well oriented;
she knows who she is, where she is and the time of the day.
Both short term and long term memory are intact. The
patient is well groomed .Normal thought processes.
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10. Skin
Acne on the face
Normal temperature of 36.9 degrees Celsius, normal turgor
and pressure. No ulcers or rash
10 Nursing Diagnosis
Inadequate nutrition, more than body requirements related
to taking of foods with excess fats, sugar and salt
evidenced by patients diet that includes fast food everyday
and Body mass index of 40.42
Patient goal: In the next one month, the patient should
reduce the number of times she takes fast foods to twice a
Interventions: Assist the patient to develop a diet plan for
the next month. Health education on the need to adhere to
the diet plan
Noncompliance with treatment evidenced by patient
skipping antihypertensive medications for two weeks.
Patient goal: Within the next month the patient should
strictly adhere to her medications and should come for
refill on the specified date
Intervention: Health education on the risks of uncontrolled
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100 Total