Sample Health Care Paper on Health Assessment, Health History and Nursing Diagnosis

Health Assessment, Health History and Nursing Diagnosis

  1. A brief medical/health history

The client by the name Ms. Jones is a 92- years old female who has a past medical history of dementia, asthma, osteoarthritis, COPD, and is considered legally blind. She is continent of bowel and bladder and currently lives in a long-term care facility and is receiving hospice care. She was recently diagnosed with both a productive cough accompanied by shortness of breath and pneumonia. Additionally, Ms. Jones had also a complain about chronic bilateral knee pain and She wears dentures

  1. Summary of laboratory diagnostic results related to pneumonia and what they mean

Human body’s reaction to pneumonia is determined by the type of germ that caused the infection, your age, and your overall health. On the basis of your symptoms and results from imaging tests that examine your lungs, the doctor may frequently be able to quickly determine whether you have pneumonia (Brooks et al.,2018), these symptoms may include; fever, shallow breath, stabbing chest pain, confusion in old adult, Shortness of breath and cough. Ms. Jones experiences same symptoms as those for Pneumonia and these symptoms were shortness in beathing, coughing and due to her age, she is most likely prone to be affected by pneumonia bacteria. Due to these symptoms, Ms. Jones was suspects to have pneumonia, and the following tests recommend;

Blood test, Ms. Jones blood was tested and the following abnormal results were found:

Hgb 10.1gm/dL (normal 13.5gm/dL-17.5gm/dL)

Hct 32% (normal 41-50)

WBC 12,500 (normal 4500-11000 mm 3)

Phosphorous 5.5 (normal (3.4-4.5)

BUN 18mg/Dl (7-20)

Albumin 2.8 (normal 3.4-5.4 g/dL Glucose 161 mg/dL (normal 70-99)

AST 45 units (normal 5-40 units) Arterial blood gas 8.20 (normal 7.35-7.45

Normal white blood cell count ranges from 4,500 to 11,000 cells/mcL, for Ms. Jones her WBC was higher than normal; 12500 counts, this leads to a conclusion that she was affected with pneumonia bacteria. The number of Hgb in her red blood cell were abnormal. Her Hgb was 10.1 and the normal Hgb ranges from 13.5 gm/dL to 17.5gm/dL.

Albumin range; Serum albumin levels in patients with pneumonia were significantly lower than in those without pneumonia from the results (Yang et al., 2020), Ms. Jones had low albumin than the normal range.

Chest X- ray was also used, and the result found were lung consolidation and pleural effusion. This was seen on the x-ray image. When Chest X ray was done on Ms. Jones, the image showed that there was lung consolidation and pleural effusion. Lung consolidation, is a condition where another substance replaces the air that typically fills the tiny airways in your lungs whereas pleural effusion is the abnormal buildup of fluid in the space between the tissue layers that line the lungs and chest cavity.

Additionally, Sputum test that was also used. This was used to check the signs of bacteria that causes pneumonia to Ms. jones. Sputum, is a viscous mucus produced by the lungs, commonly known as phlegm. Its thickness aids in the trapping and removal of infections from the lungs. As a result, sputum can be examined for evidence of bacteria, viruses, or other pathogens.

  1. Summary of a head to toes physical assessment

The physical assessment of the patient with pneumonia began with an inspection of the head and face. The patient appeared to be in moderate distress, with a flushed face and beads of sweat on the forehead. The eyes were sunken and the pupils were dilated. The lips were dry and the mouth was open. The nose was pale and the nostrils were flared. There was a fine tremor in the hands and the fingers were drumming on the bed.

The chest was examined next, a stethoscope is often was to listen to the lungs. It was tap on Ms. Jones chest and she request to take several breaths while listening certain noises related to pneumonia such as wheezing or cracking of sounds, respiratory rate are checked to assess the severity of the illness.

The abdomen was soft and non-tender. There was no evidence of peritoneal irritation. Following that, the extremities were examined. The muscles were weak, and the hands trembled slightly. The pulses were light and thin. The skin was clammy and chilly. Additional symptoms that were discovered during physical assessments were fever, low body temperature, shortness of breath, cough, fever, and difficulty breathing

Finally, the patient was determined to have pneumonia, with increased work of breathing, generalized wheezing, and crackles at the lungs’ bases. In addition, the patient was dehydrated and had a low blood pressure.


  1. Your nursing diagnosis

The nursing diagnosis that was observed on Ms. Jones that are related with pneumonia were coughing, shortness of breath, rapid breathing, sweating and fever (Wielders et al., 2014). Pneumonia can be caused by a variety of bacteria, viruses or fungi, and can range in severity from mild to life-threatening. Treatment typically involves antibiotics and supportive care.





Bickley, L., & Szilagyi, P. G. (2012). Bates’ guide to physical examination and history-taking. Lippincott Williams & Wilkins.

Brooks, L. R., & Mias, G. I. (2018). Streptococcus pneumoniae’s virulence and host immunity: aging, diagnostics, and prevention. Frontiers in immunology9, 1366.

Shinde, S., Oak, J., Shrawagi, K., & Mukherji, P. (2021, December). Analysis of WBC, RBC, Platelets Using Deep Learning. In 2021 IEEE Pune Section International Conference (PuneCon) (pp. 1-6). IEEE.

Wielders, C. C., Wuister, A. M., de Visser, V. L., de Jager-Leclercq, M. G., Groot, C. A., Dijkstra, F., … & Schneeberger, P. M. (2014). Characteristics of hospitalized acute Q fever patients during a large epidemic, The Netherlands. PLoS One9(3), e91764.

Yang, X., Wang, L., Zheng, L., Wu, J., Liu, J., Hao, Z., … & Wang, D. (2020). Serum albumin as a potential predictor of pneumonia after an acute ischemic stroke. Current Neurovascular Research17(4), 385-393.