Health Assessment of a 62-Year-Old Adult With a 30 Pack-Year Smoking History: Findings, Interpretation, and a Screening Plan
Student Name
School of Nursing, Aspen University
N495: Health Assessment
Instructor Name
Month Day, Year
Health History and Risk Profile
The client is a 62-year-old man seen in an outpatient primary care clinic for a wellness visit, his first contact with any clinic in about four years. He is a composite created for this model paper, and no real person, employer, or clinic is described anywhere in it. He reports shortness of breath climbing one flight of stairs over the past six months, which he attributes to being out of shape, and a morning cough productive of a small amount of clear sputum on most days for roughly two years. He denies chest pain, orthopnea, leg swelling, fever, unintended weight loss, and blood in the sputum.
He has smoked one pack of cigarettes daily since age 32, a 30 pack-year history, and has made no quit attempt in the past twelve months, though he says he has thought about it since his daughter asked him to stop. He drinks three to four beers on two nights out of seven and none on the other five. He walks roughly 2,000 steps a day, eats processed meat five or more times every seven days, and works a day schedule with no occupational dust or fume exposure. He takes no prescription medicines and has no known allergies. He has never had a colonoscopy. His father was diagnosed with colon cancer at 68.
Two patterns are already visible before anyone touches a stethoscope. Exertional breathlessness with a chronic productive cough in a long-term smoker is the ordinary presentation of chronic airflow limitation, and it moves the respiratory examination to the center of this visit rather than to the end of a checklist. Separately, he reports snoring loudly, sleeping about six hours, and waking unrefreshed, which raises the question of obstructive sleep apnea and justifies a validated sleep screening questionnaire under clinic protocol. Recording the history this way also does something practical for the reader: it explains why the examination that follows was weighted the way it was.
Physical Examination Findings and What They Mean
Vital signs were taken after five minutes of seated rest with the feet flat, the arm supported at heart level, and a large adult cuff, because an undersized cuff and an unsupported arm each push a reading upward on their own (Jarvis, 2020). Blood pressure measured 152/94 in the right arm, 150/92 in the left, and 148/92 on repeat after a further five minutes. Heart rate was 82 and regular, respirations 18 and unlabored, temperature 36.8 degrees Celsius, and oxygen saturation 95 percent on room air. Height was 178 cm, weight 98 kg, body mass index 30.9, and waist circumference 108 cm.
Read against expected findings, three readings at or above 140/90 in one sitting sit in the stage 2 range of the adult blood pressure categories, but one visit does not make a diagnosis, and the accurate interpretation is elevated readings that require confirmation on a separate day and outside the clinic. The waist circumference carries its own meaning and is not a restatement of the body mass index: 108 cm is above the 102 cm threshold used for men, and central adiposity raises cardiometabolic risk even where a body mass index of 30.9 alone would be read as class 1 obesity. Taken together rather than singly, the two findings set the priority for this visit.
On respiratory examination, chest expansion was symmetric, there was no accessory muscle use, and breath sounds were diminished at both bases with a prolonged expiratory phase and no wheeze or crackles at rest. Cardiac examination found S1 and S2 without murmur, gallop, or rub, no jugular venous distension, pedal pulses 2+ and equal, and no peripheral edema. Those cardiac findings are relevant negatives rather than filler, because they make heart failure an unlikely explanation for the breathlessness and leave the airway as the pattern that fits the history. The respiratory findings are documented and reported to the provider the same day; attaching a diagnosis to them is not a registered nurse function.
Screening and Immunization Recommendations With Eligibility and Interval
A screening recommendation is only usable when it carries the eligibility rule and the interval, so each one below states both. Annual low-dose computed tomography for lung cancer applies to adults aged 50-80 with a 20 pack-year or greater history who currently smoke or who quit within the past 15 years (U.S. Preventive Services Task Force [USPSTF], 2021b). At 62, with 30 pack-years and current use, he is eligible today, the interval is yearly, and screening stops once 15 years have passed since quitting. Colorectal cancer screening applies to adults aged 45-75, and he has never been screened, so at 62 he is years overdue; the standard intervals are colonoscopy every 10 years or a fecal immunochemical test yearly (USPSTF, 2021a).
Screening for prediabetes and type 2 diabetes applies to adults aged 35-70 who are overweight or obese and repeats about every three years, and a body mass index of 30.9 makes him eligible now (USPSTF, 2021c). Blood pressure screening is recommended for all adults, with confirmation outside the clinic before any diagnosis is made, and hepatitis C screening is a one-time test for adults aged 18-79 (USPSTF, 2024). One recommendation is included here precisely because he does not meet it. One-time ultrasound screening for abdominal aortic aneurysm applies to men aged 65-75 who have ever smoked, and at 62 he is three years short of eligibility, so it is flagged in the record for his 65th birthday instead of being arranged today.
Immunizations follow the same rule of eligibility plus interval. A tetanus, diphtheria, and pertussis booster is due every 10 years, and his last dose is undocumented, which is handled as unvaccinated until a record is located. Two doses of recombinant zoster vaccine are recommended for adults aged 50 and older, and pneumococcal vaccination now begins at age 50, so both apply to him today. Influenza vaccine is annual, and COVID-19 vaccination follows the schedule current for the season (Centers for Disease Control and Prevention, 2025). None of this is ordered by the nurse; each item is checked against the state immunization registry, offered under clinic standing orders where they exist, and otherwise carried to the provider.
Nursing Priorities, Teaching Plan, and Referral
Three nursing priorities come out of this visit, ranked by what would harm him soonest. First is untreated elevated blood pressure in a man with no established source of care. Second is tobacco use in someone who already has examination findings consistent with airflow limitation. Third is a screening backlog that includes two cancers for which he has been eligible for years. Ranking them is part of the work, because a plan that treats every finding as equally urgent gives the client nothing to act on first, and he leaves the clinic holding a list rather than a next step.
For the blood pressure priority, the teaching plan is home measurement, taught by demonstration and confirmed by teach-back: correct cuff placement, five minutes of quiet sitting, feet flat on the floor, no talking, two readings each morning and evening, logged for seven days before the follow-up appointment. For tobacco, the counseling is brief and structured, ends in a specific offer rather than general advice, and includes a referral to the state quitline and a conversation with the provider about medication support. The outcomes that will show whether any of this worked are a completed 14-reading home log, an attended appointment within 14 days, and a documented quit date.
Where registered nurse scope ends is stated plainly rather than blurred. Everything above is history taking, examination, interpretation against expected findings, teaching, and referral. Assigning a diagnosis of hypertension or chronic obstructive pulmonary disease, ordering spirometry or laboratory work, and prescribing medication belong to the provider, and this write-up is stronger for saying so than for implying a wider role. The findings, the interpretations, and the screening list went to the provider the same day, and the follow-up appointment, the quitline referral, the hepatitis C flag, and the aneurysm screening flag for age 65 were all entered in the record before the client left.
References
Centers for Disease Control and Prevention. (2025). Recommended adult immunization schedule for ages 19 years or older, United States, 2025. U.S. Department of Health and Human Services.
Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.
U.S. Preventive Services Task Force. (2021a). Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA, 325(19), 1965-1977.
U.S. Preventive Services Task Force. (2021b). Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA, 325(10), 962-970.
U.S. Preventive Services Task Force. (2021c). Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA, 326(8), 736-743.
U.S. Preventive Services Task Force. (2024). A and B recommendations. Agency for Healthcare Research and Quality.
How this N 495 Module 4 example is structured
This N495 Module 4 example follows the order a health assessment is actually performed and charted. Subjective data comes first, because the history decides which parts of the examination matter most. Objective findings follow, each read against what would be expected rather than parked in a list. The third section turns the risk picture into screening and immunization recommendations, and every line carries who is eligible and how often it repeats, including one the client does not qualify for yet. The last section ranks nursing priorities, sets the teaching plan, and marks where registered nurse scope ends. In many sections this module of Health Assessment at Aspen University asks for a written adult assessment built from a history and an examination; your classroom's instructions decide the exact form.
N495 Module 4 questions, answered
What does N495 Module 4 usually ask for?
In many sections the middle modules of this course ask for a written adult health assessment: a documented history, a physical examination, interpretation of the findings, and a health promotion plan. At the RN-to-BSN level it stays in registered nurse scope, meaning you document, interpret, teach, and refer rather than diagnose or order. Your classroom instructions decide the exact form.
What makes a finding interpreted rather than listed?
A listed finding reports a number or a sound. An interpreted finding says what it means against what was expected, and what it rules in or out. Blood pressure of 152/94 becomes elevated readings requiring confirmation off site. Absent edema and absent jugular venous distension become a reason to look at the airway instead of the heart.
Whose health assessment can you write up for this paper?
Use a composite client, or a consenting adult volunteer if your instructions allow one, and never a patient from work. No employer, clinic, colleague, or patient may be identifiable, and chart data should not leave the workplace. The paper above uses a composite and says so once, in plain words, in the first paragraph.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.