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health Assessment

Conduct a health history on a family member or friend. You can use the form located in your Health Assessment lab manual book from classroom assignment. You do not need to submit the health history form with your paper. Be sure they give you permission. Using the interviewing techniques learned in Module 2, gather the following information. Present Health

· Past Medical Health

· Family History

· Review of Systems

While this is only a partial health history, summarize in 3 -5 pages the information you gathered.

Include your answers to the following questions in the summary:

1. Was the person willing to share the information? If they were not, what did you do to encourage them?

2. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it?

3. How comfortable were you taking a health history?

4. What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty?

5. Now that you have taken a health history discuss how this information can assist the nurse in determining the health status of a client.

Your assignment needs to be completed in APA format & have accurate spelling and grammar.

Health Assessment

Conduct a health history on a family member or friend. You can use the form located in your Health Assessment lab manual book or from Week Two classroom assignment. You do not need to submit the health history form with your paper. Be sure they give you permission. Using the interviewing techniques learned in Module 2, gather the following information. Use your textbook as your guide.

· Present Health

· Past Medical Health

· Family History

· Review of Systems

While this is only a partial health history, summarize in 3 -5 pages the information you gathered.

Include your answers to the following questions in the summary:

1. Was the person willing to share the information? If they were not, what did you do to encourage them?

2. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it?

3. How comfortable were you taking a health history?

4. What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty?

5. Now that you have taken a health history discuss how this information can assist the nurse in determining the health status of a client.

Your assignment needs to be completed in APA format & have accurate spelling and grammar. There is an APA template located in the library.

Health Assessment

Answer the following questions in summary format AND the pain assessment summary:

1. Describe the assessment techniques discussed in the textbook. Why is it important to perform the assessment techniques in order?

2. Describe the significant characteristics of a general survey.

3. Conduct a pain assessment. Make sure you include one of the pain scales that are discussed in the textbook. Document your findings.

 

You may conduct the pain assessment on a fellow student, friend, or family member. Remember to secure their permission.

Collect both subjective and objective data using the process described in the textbook. Then, document your subjective & Objective findings on a WORD document.

APA format isn’t required.

Textbook

Physical Examination and Health Assessment

Carolyn Jarvis

8th edition

health Assessment

NUR2092 WRITE-UP—HEALTH HISTORY
Classroom Assignment Week Two

Date _04/15/2022 Examiner ___

1. Biographic Data Name ____Aisha Brown

Phone_____7737578441

Address_____1750 w farwell Chicago Illinois

Birthdate ____12/10/1988

Birthplace __Rockford Age _34 Gender _Female Marital Status __single

Occupation __Student Race/ethnic origin ___Africa American

Employer ___Walgreen

2. Source and Reliability __From patient

3. Reason for Seeking Care: Constipation

4. Present Health or History of Present Illness : None

Past Health

Describe general health ____Fair

Childhood illnesses ____Gastroenteritis

Accidents or injuries (include age) __N/A

Serious or chronic illnesses (include age) ____N/A

Hospitalizations (what for? location?) __N/A

Operations (name procedure, age) __N/A
Obstetric history: Gravida ____N/A Term __N/a Preterm _____N/A (# Pregnancies)
(# Term pregnancies) (# Preterm pregnancies)
Ab/incomplete ___N/A. Children living _____N/A (# Abortions or miscarriages) _____N/A

Course of pregnancy___N/A (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition)
Immunizations__Up to date

Last examination date: Physical _______12/12/2021

Dental ___12/05/2021 Vision ____11/28/2021 Allergies _____N/A

Reaction ___N/A

Current medications ________Miralax

6. Family History—Specify Which Relative(s)

Heart disease__________________N/A High blood pressure____YES Father

Stroke_________________________N/A Diabetes__________________N/A

Blood disorders__________________N/A Breast or ovarian cancer______N/A

Cancer (other)___________________N/A Sickle cell___________________N/A

Arthritis_________________________N/A
Allergies________________________N/A Asthma ___________________N/A

Obesity_________________________N/A Alcoholism or drug addiction __N/A

Mental illness ____________________N/A Suicide ___________________N/A

Seizure disorder __________________N/A Kidney disease _________________N/A

Tuberculosis _____N/A

Review of Systems (Circle/highlight both past health problems that have been resolved and current problems, including date of onset.)

General Overall Health State: Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats: NONE

Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion:NONE

Hair: Recent loss, change in texture : NONE

Nails: Change in shape, color, or brittleness: NONE

Health Promotion: Amount of sun exposure, method of self-care for skin and hair
N/A

Head: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo:NONE

Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts :NONE

Health Promotion Eyes: Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if any N/A

Ears: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo N/A

Health Promotion Ears: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears

Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell:NONE

Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste:NONE

Health Promotion/Mouth & Throat: Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup

Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter:NONE

Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rash:NONE

Health Promotion Breast: Performs breast self-examination, including frequency and method used, last mammogram and results:NONE

Respiratory System: History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure Health Promotion Respiratory: Last chest x-ray examination: NONE

Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia

Health Promotion Cardiovascular: Date of last ECG or other heart tests and results: NONE

Peripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers Health Promotion Peripheral Vascular: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose: NONE

Gastrointestinal System: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula)

Health Promotion Gastrointestinal: Use of antacids or laxatives

Urinary System: Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back

Health Promotion Urinary: Measures to avoid or treat urinary tract infections, use of Kegel exercises:NONE

Male Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia :NONE

Health Promotion Male Genital: Perform testicular self-examination? How frequently?NONE

Female Genital System: Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding. NONE

Health Promotion Female Genital: Last gynecologic checkup, last Pap test and results

Last pap test 02/10/2021

Result: Negative

Sexual Health: Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis) None

Musculoskeletal System: History of arthritis or gout. In the joints: pain, stiff-ness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait prob-lems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.
None

Health Promotion Musculoskeletal: How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?

Neurologic System: History of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.

Hematologic System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.
Endocrine System: History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy.

Functional Assessment (Including Activities of Daily Living)

Self-Esteem, Self-Concept: Education (last grade completed, other significant training) __College

Financial status (income adequate for lifestyle and/or health concerns) __Income adequate for lifestyle

Value-belief system (religious practices and perception of personal strengths) _____Muslim

Self-care behaviors _______Eating Healthy and Look good

Activity and Exercise: Daily profile, usual pattern of a typical day ___go to gym every sunday

Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs ___________________None

Leisure activities ______________Spend with friends

Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring Treadmill every sunday

Sleep and Rest: Sleep patterns, daytime naps, any sleep aids used ___________________

Nutrition and Elimination: Record 24-hour diet recall. ___No diet restriction

Is this menu pattern typical of most days? __No

Who buys food? _______________________Patient buy food

Who prepares food? ____________________Patient prepare the food

Finances adequate for food? ______________yes

Who is present at mealtimes? _________________patient

Interpersonal Relationships and Resources: Describe own role in family ______very well

How getting along with family, friends, co-workers, classmates _____________very well

Get support with a problem from? _____________________________________Boyfriend

How much daily time spent alone? ____________________________________NONE

Is this pleasurable or isolating? ___________________________________________Pleasureable

Coping and Stress Management: Describe stresses in life now ___Combing school with work

Change(s) in past year _______________________________None

Methods used to relieve stress _____________________Watch movies

Are these methods helpful? _______________________yes

Personal Habits:

Daily intake caffeine (coffee, tea, colas) ___None

Smoke cigarettes? __________No Number packs per day _____N/A

Daily use for how many years ________NO Age started __NO

Ever tried to quit? _________________N/A How did it go? ____N/A

Drink alcohol? _______________N/A Date of last alcohol use _____ N/A

Amount of alcohol that episode ___________________________________N/A

Out of last 30 days, on how many days had alcohol? ____________________NO

Ever told had a drinking problem? ____NO

Any use of street drugs? ___NO Marijuana? ________NO

Cocaine? _____________NO Crack cocaine? _______NO

Amphetamines? _______NO Heroin? _________NO

Prescription painkillers? _________NO Barbiturates? _______NO

LSD? ________________NO

Ever been in treatment for drugs or alcohol? __NO

Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors) ___Apartment

Safety of area _______Good

Adequate heat and utilities ___yes

Access to transportation _____Car

Involvement in community services __No

Hazards at workplace or home _____N/A

Use of seatbelts _Yes

Travel to or residence in other countries ___N/A

Military service in other countries __________N/A

Self-care behaviors _____________________________________________________________________ Intimate Partner Violence: How are things at home? Do you feel safe? __YES

Ever been emotionally or physically abused by your partner or someone important to you___-NO

Ever been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner? ___NO

Partner ever force you into having sex? ____NO

Are you afraid of your partner or ex-partner? __NO

Occupational Health:

Please describe your job. ___Work at Walgreen as Pharmacy tech

Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? __no

Any equipment at work designed to reduce your exposure? N/A

Any work programs designed to monitor your exposure? _N/A

Any health problems that you think are related to your job? ____N/A

What do you like or dislike about your job? ____Help to improve other lives’ but its stressful somethings

Perception of Own Health:

How do you define health? ______State of complete physical, mental and social well-being and not merely the absence of disease or infirmity

View of own health now _________Healthly

What are your concerns? _____None

What do you expect will happen to your health in future? __Expect to remain healthy in future

Your health goals ________Eat healthy, exercise more and maintain a healthy life

Your expectations of nurses, physicians _____friendly atmosphere, listen to all my complain, speck to me calmly and follow up with my concerned

Health Assessment

Answer the following questions in summary format AND the pain assessment:

1. Describe the assessment techniques discussed in the textbook. Why is it important to perform the assessment techniques in order?

2. Describe the significant characteristics of a general survey.

3. Conduct a pain assessment. Make sure you include one of the pain scales that are discussed in the textbook. Document your findings.

 

You may conduct the pain assessment on a fellow student, friend, or family member. Remember to secure their permission.

Collect both subjective and objective data using the process described in the textbook. Then, document your subjective & Objective findings on a WORD document.

APA format isn’t required. 

Health Assessment

Weekly assignment: conduct an assessment on the following:

  • Heart & Lungs

You may conduct the assessment on a fellow student, friend, or family member. Remember to secure their permission.

Collect both subjective and objective data using the process described in the textbook. Then, document your subjective & Objective findings in a narrative note on a WORD document. APA format isn’t required. 

    • 10

    Health Assessment

    Partner Health History Paper

    Stratford University

    NSG 330

    February 22, 2022

    Partner Health History


    Health History


    Biographic Data

    Name: J.C

    Address: 784 Greenwood Street, Laurel, OH 29103

    Date of Birth: 02/09/1971

    Birthplace: Dallas, TX

    Marital Status: Single

    Occupation: Lawyer

    Race/Ethnicity: Black/ American

    Health History

    Reason for seeking care: Chest pain

    History of Present Illness: This is the first Hospital admission for this 52-year-old lawyer with a history of hypertension. Mr. J.C noted the abrupt onset of a dull aching pain in the retrosternal area while delivering a summation in court. The pain radiated into his left arm and upper jaw, was associated with a feeling of queasiness, and sweating and lasted 10 minutes. He sat down and let his associate finish the summation and the pain went away spontaneously after 5 minutes. Later that afternoon, while playing squash, he had the onset of similar but more severe aching pain, in the same distribution, associated with queasiness, sweating and weakness. An ambulance brought him to Greenville’s Emergency Department. This pain lasted about 30 minutes and was relieved when he was given NTG. He says he has “borderline cholesterol.” His father died of a myocardial infarction at age 54; one brother aged 47 has heart disease. He has never smoked. He denied any shortness of breath, palpitations, previous similar pain, diabetes or known cardiac disease.

    Past Medical History:

    Mild asthma as child-now completely resolved

    Chickenpox – age 7

    Eczema—still has mild and infrequent

    Hypertension, first noted at age 47- does not know if it is controlled with meds

    Past Surgical History:

    Tonsillectomy – age 5

    Appendectomy – age 18

    Vasectomy – age 42

    Injuries:

    Fractured tibia while skiing – age 38

    Immunizations:

    Normal childhood immunizations

    Last tetanus shot – age 38 when had the tibial fracture

    Complete Covid vaccine

    Medications:

    Norvasc 5 milligrams daily po

    Multivitamin over the counter

    Allergies:

    Not known.

    Health Maintenance Screening

    Last eye exam 1 year ago- reportedly normal

    Hemoccult check for blood in stool – 6 mos. ago –negative per pt

    Prostate exam – 6 mos. ago- normal per pt

    Family History

    Father – died at age 54 -MI, was hypertensive

    Mother – 76, alive and well 

    2 siblings: Brother – 47 – S/P MI

    Sister – 49 healthy

    3 children: Son – 28, healthy

    Son – 25- asthma

    Daughter – 22 healthy

    Social History

    Attended University of Pennsylvania and Villanova Law School. Works as partner in law firm. His job is extremely stressful. He is currently separated from his wife, and lives with his girlfriend. He is only sexually active with her and has no problems. Does not use condoms. They have a turtle. He has three children with whom he has a close relationship and feels he has a good support system. ETOH: a glass of wine with dinner. Denies drug use. Does not exercise regularly except for playing occasional squash. No blood transfusions. No chemical exposure or recent foreign travel. No history of abuse.

    Review of Systems:

    General: gained 20 pounds gradually over past yrs. no fever, chills, sweats, fatigue.

    Skin: no rashes, photosensitivity.

    Head: “sinus headache”, no history of head injury

    Eyes: wears reading glasses, no history of eye pain, red or pink eye, decreased tearing or eye discharge. Saw ophthalmologist last year.

    Ears: denies difficulty hearing, ear infection, discharge or dizziness

    Nose: recurrent seasonal rhinitis (tree pollen in the spring), no epistaxis. Has had recurrent sinusitis, ENT doc tells him he has polyps

    Mouth and Throat: recurrent cold sores, no recent sore throat Respiratory: denies shortness of breath, cough, hemoptysis, positive TB test or exposure. No recent wheezing; no orthopnea, PND.

    Cardiac: see HPI

    Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or bleeding per rectum. Takes Metamucil for irregularity at times.

    Genito-urinary: No hematuria, dysuria or urinary hesitancy. No penile discharge.

    Endocrine: no change in skin or hair, no polyuria or polydipsia, no hoarseness, dysphagia, intolerance to temperatures

    Vascular: No claudication or ulcers. No varicose veins.

    Musculoskeletal: Tennis elbow right arm, intermittently, uses a splint when he plays squash. No gout, arthritis, back pain

    Neurological: no history seizure, no sensory loss, no motor weakness, no migraines, no paresthesia Psychiatric: seeing a therapist regarding the separation from his wife

    Functional Assessment
    :

    Self-Esteem/ Self Concept: Graduated high school and have professional degree in law.

    Financial Status: Sufficient, having a good financial status.  

    Value/ Belief System: Buddhist. 

    Self-Care Behaviors: Have excessively good family time with girlfriend and his Children.

    Activity/ Exercise ADL’s: Active lifestyle. She has a very strict timetable in both social and professional life. Exercise regularly before going to duty and have continuous working activity.

    Sleep and Rest: Sleep deprivation. Approximately 7 hours of sleep in a day.  

    Nutrition and Elimination: He was a food lover in past and loves sweets. He has a very tough duty and mostly eats outside.  Girlfriend prepares food for him occasionally. He reports that his loss of appetite is quite crucial for last two months.  

    Interpersonal Relationships and Resources: She works for her family and enjoys a strong bond with all her siblings, husband, son and her in-laws. 

    Coping and Stress Management: He is suffering from anxiety and takes sleeping pills for stress release. No addictive habits.  

    Personal Habits: Morning meditation: 20 minutes of meditation every morning before the day activities, non-smoker, non-alcoholic. JC reported having a cup of hot cocoa and brushing his teeth every night before going to bed 

    Environment and Hazards: J.C lives in a double story house in Dallas Texas. He is a tenant and lives on the upper story. High risk of fall and imbalance while climbing the stairs is expected. He reports that her neighbors are quite friendly.

    Intimate Partner Violence: Feels safe at home, no abuse reported. No report of mental, psychological, or otherwise physically hurt by partner. Partner has never forced him into having sex. No report of threat from anyone. He enjoys excellent family relationships with all his family members.

    Occupational Health: He works at a law firm. Occupational hazards like depression and workaholism chances are quite evident. 

    Perception of Own Health: He was a bit worried about his current weight and not exercising often. He viewed himself as not physically fit and that might not be good for his overall health.

    Future Goals: He has decided to follow a complete diet plan and prescribed medicines. Also, to be more active by exercising 30 minutes every day.

    Health Assessment

    NSG330 Health Assessment and Diagnostic Reasoning

    Grading Criteria for Partner Complete Physical

    Student Name:__________________________________________ Date:____________________

    Format

    Possible Points

    Student’s Score

    Paper is typed and turned in on time, with coversheet

    5

    Words in physical are selected by student and not copied directly from a textbook.

    5

    Content

    Possible Points

    Student’s Score

    General Survey

    10

    Measurements

    5

    Head to Toe Examination

    30

    Assessment and Plan

    Give 2 Nursing Diagnoses with at least two interventions for each

    30

    SOAP Note

    15

    Total

    100 points

    Actual points =

    Student may also use Chapter 28 in Jarvis textbook as guide and samples of a complete physical examination

    Health Assessment

    Weekly assignment: conduct an assessment on the following body systems:

    • Peripheral vascular, musculoskeletal and neurological

    You may conduct the assessment on a fellow student, friend, or family member. Remember to secure their permission.

    Collect both subjective and objective data using the process described in the textbook. Then, document your subjective & Objective findings in a narrative note on a WORD document. APA format isn’t required. 

    1 full page

    Health assessment

     

    The nurse proceeds to palpate the lymph nodes. Which lymph nodes are located in the neck? 

    1. Please indicate all the Lymph nodes in the neck 

    2. What is the Rationale for performing this assessment. 

     

    3. When performing the physical examination, what objective data should the nurse inspect and palpate for the head and neck?
    4. What is the Rationale for question # 3

      • 10

      health assessment

      Name:

      Section:

      Week 5

      Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

      SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

      Chief Complaint (CC):

      History of Present Illness (HPI):

      Medications:

      Allergies:

      Past Medical History (PMH):

      Past Surgical History (PSH):

      Sexual/Reproductive History:

      Personal/Social History:

      Immunization History:

      Significant Family History (Include history of parents, Grandparents, siblings, and children):

      Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

      General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

      HEENT:

      Respiratory:

      Cardiovascular/Peripheral Vascular:

      Psychiatric:

      Neurological:

      Lymphatics:

      OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

      Physical Exam:

      Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry

      General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

      HEENT:

      Respiratory: Always include this in your PE.

      Cardiology: Always include the heart in your PE.

      Lymphatics:

      Psychiatric:

      Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)

      ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.

      © 2021 Walden University

      health assessment

      FOLLOW THE INSTRUCTIONS:
      Assignment Option 2: Child Health Case:

      23-year-old Chinese American female freshman college student struggling with weight loss.

      Assignment 1: Case Study Assignment: Assessment Tools and Diagnostic Tests in Adults and Children

      When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors to select the most appropriate test or tool and to accurately interpret the results.

      Not only do these diagnostic tests affect adults, but body measurements can also provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process.

      For this Assignment, you will consider the validity and reliability of different assessment tools and diagnostic tests. You will explore issues such as sensitivity, specificity, and positive and negative predictive values. You will also consider examples of children with various weight issues. You will explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight.

      To Prepare

      Review this week’s Learning Resources and consider factors that impact the validity and reliability of various assessment tools and diagnostic tests. You also will review examples of pediatric patients and their families as it relates to BMI.

      By Day 1 of this week, you will be assigned to one of the following Assignment options by your Instructor: or Child Health Case (Option 2).

      Search the Walden Library and credible sources for resources explaining the tool or test you were assigned. What is its purpose, how is it conducted, and what information does it gather?

      Also, as you search the Walden library and credible sources, consider what the literature discusses regarding the validity, reliability, sensitivity, specificity, predictive values, ethical dilemmas, and controversies related to the test or tool.

      If you are assigned Assignment Option 2 (Child), consider what health issues and risks may be relevant to the child in the health example.

      Based on the risks you identified, consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.

      Consider how you could encourage parents or caregivers to be proactive toward the child’s health.

      The Assignment

      Assignment (3–4 pages, not including and reference pages):

      Assignment Option 2: Child Health Case:

      Include the following:

      An explanation of the health issues and risks that are relevant to the child you were assigned.

      Describe additional information you would need to further assess his or her weight-related health.

      Identify and describe any risks and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.

      Considering the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information.

      Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight.

      health assessment

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      Documentation / Electronic Health Record

      Document: Nursing Notes

      Student Documentation Model Documentation

      Subjective

      Danny Rivera is an 8-year-old male who presents for evaluation of a
      cough of onset 3 days ago. Patient reports a productive cough with
      “slimy, clear” sputum. The patient reports a sensation to cough
      “every few minutes” and his coughing spells last “a couple
      seconds”. The patient reports an exacerbation of his symptoms at
      night causing him to have difficulty sleeping. The patient reports that
      his friend he played with a few days ago is also sick with symptoms
      of a cough and rhinorrhea. The patient reports that his mother has
      been giving him cough medicine which was noted by his
      grandmother to be children’s Dimetapp daytime formula. The child
      last received the Dimetapp this morning and noted improvment of
      his symptoms after taking the medication. The patient notes
      associated symptoms of “feeling tired” but notes that he is able to
      play at school normally until he feels the urge to cough. He also
      notes associated “clear” watery rhinorrhea and a sore throat with
      exacerbation with swallowing. The patient notes a normal level of
      focus at school but reports it is “harder than normal” to pay attention
      due to freqwuent coughing. The patient denies any symptoms of
      sneezing, ear pain, ear drainage, hearing changes, fever, chills, night
      sweats, HA, vision changes, dizziness, eatery eyes, sinus pain, chest
      pain, or difficulty breathing. The patient was sent to my office for
      evaluation by his teacher due to persistent cough. He reports no
      other associated sx or complaints at this time.

      Contacted guardian: Patients grandmother reports a cough for the
      past 3 days and states that Danny “hasn’t been himself”. Reports
      that patient was given children’s Dimetapp, daytime formula this
      morning before going to school. Grandmother confirms that the
      patient has had a normal temperature the past few days. Reports
      history of a pneumonia one year ago and frequent ear infections but

      Danny reports a cough lasting two to three days. He describes the
      cough as “watery and gurgly.” He reports the cough is worse at night
      and keeps him up. He reports general fatigue due to lack of sleep.
      He is experiencing mild soreness in his throat. He reports his mother
      treated his cough symptoms with over-the-counter medicine, but it
      was only temporarily effective. He reports frequent cold and runny
      nose, and he states that he had frequent ear infections as a child. He

      Your Results Reopen (/assignment_attempts/7298943/reopen)
      Lab Pass (/assignment_attempts/7298943/lab_pass.pdf)

      Overview

      Transcript

      Subjective Data Collection

      Objective Data Collection

      Education & Empathy

      Documentation

      Care Plan

      Document: Vitals Document: Nursing Notes

      Support

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      7/10/20, 12(24 AMFocused Exam: Cough | Completed | Shadow Health

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      “seems to be doing better this year”. Grandmother reports that his
      cough has not worsened or improved in the past few days and the
      patient has been coughing more at night. Patient’s grandmother has
      applied a “cough rub” to the patient’s chest before he goes to sleep
      at night. The patient has not been evaluated by his primary
      physician. Grandmother is coming to pick up Danny at this time.

      PMHx:
      The patient reports a history of frequent OM as a baby but denies
      any recent ear complaints. The patient was diagnosed with PNA one
      ear ago.
      He denies any allergies to medications or foods. Patient denies any
      seasonal allergies.

      The patient reports that he takes a daily multivitamin and
      “sometimes sneakd a few extra” because they taste good. The
      patient has been informed to not take more than the prescribed
      amount of daily vitamins and verbalized understanding.

      The patient reports infrequent hand hygiene throughout the day. The
      patient was educated on the importance of hand hygiene to prevent
      the spread of germs and was encouraged to practice more frequent
      hand washing throughout the day. Patient verbalized understanding.

      FHx:
      The patient reports exposure to secondhand smoke at home due to
      his father sometimes “smoking cigars in the house”. The patients
      father has a pmhx per patient of HTN, HLD and childhood asthma.
      His mother has a pmhx per patient of DM, HLD, and HTN.

      reports a history of pneumonia in the past year. He reports normal
      bowel movements. He denies fever, headache, dizziness, ear pain,
      trouble swallowing, nosebleed, phlegm or sputum, chest pain,
      trouble breathing and abdominal pain. He denies cough aggravation
      with activity.

      Objective

      Eyes: Upon inspection, patients eyes have no visable abnormal
      findings bilaterally. Sclera: white bilaterally. Conjunctiva: Moist and
      pink bilaterally. No conjunctival drainage bilaterally.

      Nose: Nasal cavities pink and patent bilaterally. Clear nasal
      discharge noted bilaterally. No other additional visable abnormal
      findings noted on inspection.

      Ears: Bilateral auditory canals pink in color on inspection. Bilateral
      TMs pearly gray in color, no visible abnormal findings bilaterally. No
      discharge noted bilaterally. Right TM cone of light noted at 0500
      position. Left TM cone of light noted at 0700 position.

      Mouth: Oral mucosa moist and pink, no visible abnormal findings
      noted to bilateral tonsils. Throat is red with present of cobblestoning
      on inspection. No post nasal drip noted.

      Sinuses: No TTP noted to frontal or maxillary sinuses.

      Neck: Symmatric with no visible findings on inspection. Palpable
      lymph nodes with TTP to right cervical lymph nodes. Supraclavicular
      and axillary lymph nodes were not palpable.

      Chest: Symmetric expansion and no vision abdnormal findings noted
      on inspection.
      All areas resonant with no areas of dullness on percussion.
      Diaphramatic excursion noted to be 3cm. On palpation, expected
      fremitus is noted and equal bilaterally. Palpated chest wall expansion
      is equal bilaterally.

      Lungs: Breast sounds noted in all areas. No adventitious
      breathsounds noted throughout all lung fields. All areas clear.

      Bronchophony: negative

      Heart: S1 and S2 audible. No extra sounds noted with auscultation.

      • General Survey: Fatigued appearing young boy seated on nursing
      station bench. Appears stable.

      • HEENT: Mucus membranes are moist, nasal discharge, and boggy
      turbinate. Fine bumps on the tongue. Cobblestoning in the back of
      throat. Eyes are dull in appearance, pink conjunctiva.

      • Cardiovascular: Mild tachycardia. S1, S2, no murmurs, gallops or
      rubs.

      • Respiratory: Respiratory rate increased, but no acute distress. Able
      to speak in full sentences. Breath sounds clear to auscultation.

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      Comments

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      HEALTH ASSESSMENT

      Episodic/Focused SOAP Note Exemplar

      Focused SOAP Note for a patient with chest pain


      S.

      CC: “Chest pain” 

      HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.

      Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg

      PMH: Positive history of GERD and hypertension is controlled

      FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives.

      SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years 

      Allergies: PCN-rash; food-none; environmental- none

      Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna

      ROS   
      General–Negative for fevers, chills, fatigue
      Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema 
      Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
      Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis  


      O.

      VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

      General–Pt appears diaphoretic and anxious

      Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the

      second right inter-costal space which radiates to the neck.

      A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

      Gastrointestinal–The abdomen is symmetrical without distention; bowel

      sounds are normal in quality and intensity in all areas; a

      bruit is heard in the right para-umbilical area. No masses or

      splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

      Pulmonary— Lungs are clear to auscultation and percussion bilaterally

      Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)


      A.

      Differential Diagnosis:

      1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

      2) Angina (provide supportive documentation with evidence based guidelines).

      3) Costochondritis (provide supportive documentation with evidence based guidelines).

      Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction


      A.

      Differential Diagnosis:

      1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

      2) Angina (provide supportive documentation with evidence based guidelines).

      3) Costochondritis (provide supportive documentation with evidence based guidelines).

      Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction


      P.
      This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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      Page 2 of 2

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      Page 1 of 2

      HEALTH ASSESSMENT

      Episodic/Focused SOAP Note Template

       

      Patient Information:

      Initials, Age, Sex, Race


      S.

      CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

      HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

      Location: head

      Onset: 3 days ago

      Character: pounding, pressure around the eyes and temples

      Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

      Timing: after being on the computer all day at work

      Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

      Severity: 7/10 pain scale

      Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

      Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

      PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

      Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

      Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

      ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

      Example of Complete ROS:

      GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

      HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

      SKIN:  Denies rash or itching.

      CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

      RESPIRATORY:  Denies shortness of breath, cough or sputum.

      GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

      GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

      NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

      MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

      HEMATOLOGIC:  Denies anemia, bleeding or bruising.

      LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

      PSYCHIATRIC:  Denies history of depression or anxiety.

      ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

      ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.


      O.

      Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

      Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)


      A

      .

      Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.


      P.
        

      This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

      References

      You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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      HEALTH ASSESSMENT

      FYI: USE THIS CASE STUDY WHILE DOING THE WORK

      Focused Throat Exam

      Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn’t take her 3-day sore throat lightly. Your clinic has treated a few cases like Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested.

      Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

      Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

      Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.


      In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.


      To Prepare

      By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

      Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

      With regard to the case study you were assigned:


      Review this week’s Learning Resources and consider the insights they provide.

      Consider what history would be necessary to collect from the patient.

      Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

      Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

      The Assignment

      Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.



      health assessment

       

      MR, a 23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help himself too. He tells you he is afraid that he will not get into heaven if he continues in this lifestyle. He is not taking any prescriptions medications and denies 

      drug use. He has a positive family history of diabetes, hypertension, and alcoholism. 

      It is very important for healthcare providers to understand the culture of their patients in history taking and assessment. In the above scenario of a 23-year-old male, it is very important that the nurse practitioner be able to recognize different culture, values and biases in other to create an effective patient center communication (Ball, Dains, Flynn, Solomon, & Stewart, 2019). In other to provide culturally competent care, it is required that healthcare providers be sensitive to the patient’s heritage, sexual orientation, socioeconomic situation, ethnicity and cultural background (Ball et al., 2019). Healthcare professionals should avoid being stereotype base on patient culture but be able to recognize their limitations in knowledge about a patient culture and maintain an open mind on their cultures.

                                                           Socioeconomic, Spiritual, Lifestyle, and other cultural factors 

      According to the scenario presented above, the 23-year-old does not have any socioeconomic factors affecting his health, but he has a spiritual and lifestyle factors that could affect his health. Culture, spirituality, and lifestyle is very important in the treatment of native Americans. The patient factor described above shows that the patient has factors like use of alcohol and drugs that may affect is health. Knowing these factors is very important in understanding the treatment approaches that are necessary to the particular individual (Indigenous Policy Journal, 2015). The patient also explains that he has anxiety about his drug use that could prevent him from reaching “heaven” when he dies In exploring this, the  nurse practitioner should be careful to not offend the patient but create rapport with the patient that can lead to a trustful one in other to implement treatment. Ask the patient to explain more about his specific beliefs and if he has a certain church or religion he follows and his thought about treatment options. I would also want to be careful when discussing his family’s medical history. Diabetes and hypertension are prevalent problems in the native community, partly due to the high rate of poverty and access to healthy foods (Struthers & Lowe, 2003). According Espey et al. (2014), there is increase mortality death rate in the native American population due to high incidence of diabetes, smoking prevalence, problem drinking, and social determinants. In this case a discussing patient perceived risk factors is a sensitive topic since patient already has anxiety because of his drug use. Proper assessment of the patient and good history taking to further find out what the patient could be more at risk for is important to provide better treatment and care. Other cultural factors that may affect the native American is that they mostly live in rural areas and are usually poor too making it difficult for them to get better healthcare. Even though not mention in the scenario above, the social determinant of the native Americans is that they are more likely than white to be poor, unemployed, and possess less education (Espey et al., 2014).

      Sensitive Issues

      The issues that the healthcare provider needs to be sensitive about when talking to the patient is the patient use of alcohol and recreational drugs.  The nurse practitioner will need to explore more by asking how often the patient drinks alcohol and uses recreational drugs. Patient also reported having anxiety. This could be from alcohol or the use of pot as mentioned. Native Americans are culturally sensitive to seek treatment for mental illness or drug/alcohol because of the stigma label on it. So, the nurse practitioner should be careful in suggesting treatment to patient. Nurse practitioner can start by asking the patient questions to find out patient stand regarding initiation of treatment (Ball et al., 2019).

                                                     Targeted Questions

      1. Do you smoke cigarettes, or are you around second-hand smoke?
      2. What do you do for a living?
      3. Within the last month has your anxiety impacted your daily living?
      4. Have you tried any natural remedies to treat your anxiety?
      5. On average, what is your daily/weekly alcohol intake?
      6. Do you have a family or community support system?
      7. Do you belong to any religious organization?

                                                                                              References

      Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

      Espey, D. K., Jim, M. A., Cobb, N., Bartholomew, M., Becker, T., Haverkamp, D., & Plescia, M. (2014). Leading Causes of Death and All-Cause Mortality in American Indians and Alaska Natives. American Journal of Public Health104(S3), S303-11. https://doi-org.ezp.waldenulibrary.org/10.2105/AJPH.2013.301798

      Indigenous Policy Journal. (2015). Native American Indian Cultural Risk Factors – Contact to Termination. Retrieved from http://www.indigenouspolicy.org/index.php/ipj/article/view/338/325

      I need a response from this discussion, 1 page

      two references