Nursing Essay Comprehensive Health Assessment for Patients and Populations
Complete Nursing Health History Biographical Data Name: B.R. Address: xxxxxxx Phone: xxxxx Gender: Female Provider of History: Client Birth Date: February 2, 1973 Place of Birth: Portland, Oregon Race: Caucasian Educational Level: Associate’s Degree in Nursing and currently pursuing Bachelor’s of Science in Nursing Occupation: Registered Nurse Significant Other: Fiancé “Mark” Support Person(s): Mother & Brother Reason for Seeking Healthcare Client is currently seeking healthcare for her yearly routine physical. Client’s last check-up with her primary physician was one year ago, at which time, no abnormal findings were noted. Client is confident with her health at this time…show more content…
Client then repeats the same schedule the next day. Nutrition Habits & Weight Management Client eats 1-2 times per day. Client admits she does not drink enough water and drinks entirely too much coffee. Client is responsible for purchasing and preparing meals for her and her fiancé. Activity Level/Exercise Client does not regularly exercise, but admits that she walks constantly at work. When not at work, client spends time either cleaning or taking her dog for walks along the beach or street. Sleep/Rest Patterns Client only gets about 6 ½ hours of sleep per night. This is a consistent pattern. She does not nap throughout the day. Medication and Substance Use Client takes Adderall 20mg daily for ADD. Client drinks coffee throughout the day. Client does not use any nicotine products or recreational drugs. She does drink alcohol socially. Self-Concept Client says she has a very positive self-concept. She is a happy person and she is excited about life and her new nursing career. Self-Care Responsibilities Client obtains bi-yearly dental exams and cleanings, receives chiropractic care every 3 weeks, bathes daily, eats healthy and is capable of performing all self-care responsibilities. Social Activities Client likes to have fun. She enjoys many outside activities, including sun bathing, boating, and going to the beach. Family Relationships Client has a close relationship with her………..
A COMPREHENSIVE HEALTH ASSESSMENT OF M. H. 2
The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient ‘s complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained…show more content…
Her current prescription medications include a 225 mg tablet of Venlafaxine HCL once daily for anxiety related dizziness, and a 20 mg tablet of Atorvastatin for high cholesterol. She drinks alcohol socially, approximately two 12 ounce beers a day. She is a former smoker of one pack of cigarettes a day for nearly forty years. Her quite date was September, 2011. She denies the use of street drugs.
A COMPREHENSIVE HEALTH ASSESSMENT OF M. H. 4
Review of Systems M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems.
No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,