Assignment on Health
assessment
Submitted by – Priyanka Submitted to – miss paramapal kaur
National college of nursing assistant professor
Msc (N) 1st year nursing national college of nursing
Health assessment
Introduction of the client
Name of the client – Mr. Manoj kumar
Age / sex - 43 /male
Occupation – private job
Education – 12 pass
Marital status – married
Health status – he is having fever
Family heath history
Manoj kumar is living in a small family . Have 4 member .
[Link] Name of the Relation Occupation Age Education Health
family with the /sex status
member head
1. Manoj kumar Head Private job 43/M 12 pass Unhealthy
2 Sunita Wife House wife 32/F 10 pass Healthy
3 Mayank Son Student 12/M 7th class Healthy
4 Sanju Daughter Student 15/F 10th class Healthy
Chief complaint
Patient having fever since 5 days . have pain in whole body and unable to take
proper diet .
History of present illness
Patient is having fever since 5 days
Sing and symptoms
Rise In temperature ( 100.1)
Loss of appetite
Weakness
Patient take paracetamole 500 mg at home but no decrease in the temperature
History of past illness
Have no any surgical history , no history of asthma , no history of
tuberculosis , no history of any cancer ,no any other allergic reaction
No history of any other tobacco chewing and smoking
No history of alcohol
Physical assessment
Head to toe examination
Face – face color is fair
Eyes – eyes are black in color .there is no discharge from the eyes , have proper
deviation between the two eye brows , have brown color hair in the eye brows ,
eye lashes are proper long and normal , no sticky material present at the eyes
lashes , proper movement of the eye ball , no pain in the eye , due to fever have
sunken eyes .
Ear – ear are clean and no discharge from the ear , hearing perception is normal ,
have wax inside the ear , no tingling sound is hear , both ear are clean
Nose -no any kind of abnormal discharge from the nose , have proper deviation of
nose by a nose bridge .
Mouth – condition of oral cavity is clean no gingivitis and stomatitis , have dry oral
cavity due to fever
Neck – have proper and normal movement of the neck ,no pain while moving , no
inflamed tonsils and lymph glands
Chest – normal
Abdomen – normal
Back – normal
Extremities – normal ,he is having minor joint pain
Hair – normal
Face – normal
Lips – normal , no cracks are present
Tongue – normal
Teeth – normal , are teeth are present , no caries are present
Gums – non – bleeding
Glands - non- enlarged
Skin – normal
Nails – normal
Oedema - absent
Rachitic changes – absent
Skin – have normal skin and no rashes and no rashes present over the skin and
no cuts are present .
Palpation
Use hand and finger to assess all over the body organ to examine the size and and
position of the organ . all organs are normal and are at their position . and
temperature quite rise .
Percussion
Percussion of the abdomen is resonance .
Lung percussion is resonant
All body organ are normal no abnormal fluid is fill ( lung , ,liver ,bladder all
are normal
There is no fluid or air filled in any organ .
Auscultation
There is no abnormal sound is heard from heart and lung check by the
stethoscope .
There is no gurgling or swishing sound heard from the lung
There is no short duration of the breathing rate
There is no sound heard from the lungs
Manipulation
Note the movement of the all body parts all body parts are move by their own
flexibility no abnormal limitation of the body part
Testing of the reflexes
All reflexes are normal.
