NR 304 Health Assessment 2 Health History

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Health History and Physical Assessment

I interviewed Mrs. BS, a 30-year-old African American woman from California who expressed concerns about a tender lump in her right breast. She rates the associated pain as 5-6 on a scale of 1 to 10 and has experienced these symptoms for three years. Mrs. BS emphasizes the significance of health in her community, where limited access to healthcare services due to disparities, poverty, unemployment, and lack of insurance promotes self-care practices. She finds intermittent relief from Ibuprofen but no relief from acetaminophen.

There is no personal history of breast trauma, surgery, or cancer, but her maternal aunt passed away from breast cancer at age 45. Mrs. BS reports skin irritation, swelling, redness, thickening, and pain in her breast. Environmental factors, including dietary habits and chemical exposure, contribute to her risk. Additionally, she smokes and lacks regular exercise. Culturally, African Americans practice self-care, while psychosocial considerations involve distrust and fear. Collaborative resources in the community offer support. Understanding Mrs. BS’s background will help provide appropriate care and support.

NR 304 Health Assessment 2 Health History

Physical Examination

During the physical examination, Mrs. BS exhibited a pleasant and cooperative demeanor. She has a height of 5’2″ and weighs approximately 120 lbs. As I assessed her musculoskeletal system, there were indications of muscle weakness. Furthermore, Mrs. BS displayed unilateral sensory loss during the neurological examination, evident through a positive Romberg test.

Moving on to her cardiovascular system, clear heart sounds were observed. However, during the examination of her respiratory system, occasional wheezes and crackles were noted bilaterally in her lungs and chest. Regarding the HEENT (Head, Eyes, Ears, Nose, and Throat) assessment, palpation of the head revealed no significant findings. The ocular examination revealed no abnormalities, and Mrs. BS demonstrated an excellent sense of smell and hearing. The assessment of the thyroid gland did not yield any significant findings. Additionally, Mrs. BS reported a recent change in her bowel elimination patterns, experiencing occasional constipation. This information is essential for evaluating her gastrointestinal function.

NR 304 Health Assessment 2 Health History

Overall, the physical examination findings suggest the presence of muscle weakness in the musculoskeletal system and unilateral sensory loss in the neurological system. The cardiovascular system exhibited normal heart sounds, while occasional wheezes and crackles were present in the respiratory system. The HEENT assessment revealed unremarkable findings except for the reported change in bowel elimination patterns. These examination findings provide valuable insights into Mrs. BS’s health status and can help guide further evaluation and management to address her presenting concerns.

Health Education Needs Assessment

The selected health education topics focus on culturally-centered preventive strategies for breast cancer, emphasizing self-breast exams and mammograms starting at the age of 40, the impact of healthy lifestyles on minimizing breast cancer risk, and health promotion activities targeting environmental and socioeconomic determinants of health in African American communities. The rationale behind these topics is to promote health behavior change, social facilitation, self-regulation skills, and knowledge to improve the health of individuals and communities. Scholarly articles support the importance of breast cancer prevention and control through education, reshaping beliefs, supporting healthy behaviors, and developing necessary health skills.

NR 304 Health Assessment 2 Health History


While interacting with Mrs. BS at her home, I ensured a holistic approach by providing a relaxing and uninterrupted environment. Acknowledging her decor and discussing family pictures helped establish rapport and cultural connection. Practical communication skills, such as active listening, empathy, and appropriate nonverbal cues, facilitated a comfortable and comprehensive health history interview. Simplifying complex clinical language overcomes communication barriers. Personal competence in diversity helped address cultural challenges. The interview process successfully obtained the necessary information and managed her questions. In the future, I will proactively learn about the interviewee’s background and culture to better understand healthcare disparities and overcome cultural barriers.


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