Abstract Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that …show more content…
Stopped after 6 months because of drowsiness. 1990: Diagnosed with peptic ulcer disease, which resolved after three months on cimetidine. She describes no history of cancer, lung disease or previous heart disease. Allergy: Penicillin; experienced rash and hives in 1985. Social History Alcohol use: 1 or 2 beers each weekend; 1 glass of wine once a week with dinner. Tobacco use: None. Medications: No prescription or illegal drug use. Occasional OTC ibuprofen (Advil) for headache (QOD). Accidents or Injuries: No automobile accident. Immunizations: Childhood immunizations up to date. Last influenza, “probably 2 years ago”. No TB skin test. Last Examinations: Last examination 2 weeks ago, general check up, told “normal”. Yearly clinical breast examination (CBE), mammography, told “normal”. Yearly Pap smear, last performed January last year, 2010. Last visit to oncologist, 2008, told “normal”. Current medications: Prescribed Antacids, Nexium, q24h, or when pain is severe, Tylenol 500 mg, PO, q12h. ------------------------------------------------- Family History R.M is the first youngest child, two sisters, healthy, parents married, father had chronic alcoholism, mother remains in perfect general health, not known disease or condition. Grandmother on father’s side T.E, died at age 78, from cardiac arrest; Grandfather on father’s side, R.M, died at age 45, from automobile accident; Grandmother on mother’s side, L.S, suffered from Parkinson, died at age 79,
It can sometimes be too late. I have learned over some years by watching those that mean a lot to me let their lives become of nothing because they do not worry about their physical appearance or the foods that they eat, and even though you can give them all the advice to try and persuade them they are determined to do what they feel and what they want to do.
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
The patient has no family history of heart disease or diabetes, however both her parents are on medication for high blood pressure. Her paternal grandmother died of breast cancer at age 47. Her maternal grandmother
When I make really good soup, they have seconds and no leftovers” (J. Lee, personal communication, May 9, 2013). No one in the family has food allergies, diet restrictions or any physical disabilities that interfere with daily food intake. Alcohol consumption is not very popular for this family. Occasional drinks are consumed “maybe five times a year, we just don’t enjoy the taste of alcohol” (S. Lee, personal communication, May 9, 2013). This family member did not experience obvious weight gain or weight loss they were concerned about. All members are very conscientious about physical appearance and do keep healthy active lifestyles and ingest healthy meals. When discussing the function of the bowel and bladder issues, S. Lee says, “We are very regular. My wife and I take Metamucil regularly to keep our bowels active. We suffered several constipations many years back, had to use enemas to eliminate. That was very painful and embarrassing. Metamucil was recommend by our doctor and we never miss taking it. Your mom suffered hemorrhoids for many years until she had them removed. We have no problem going once a day or more sometime” (S. Lee, personal communication, May 9, 2013).
Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 250 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.
Eyes, ears, mouth: Patient denies difficulty with vision or double vision. Denies any eye pain, inflammation, discharge, denies history of glaucoma or cataracts, denies hearing loss or trouble hearing, denies sore throat, dry mouth, bleeding gums. Reports regular dental visits.
Angina Pectoris is a disorder described by episodes of pain when the supply of oxygen to the heart is inadequate to meet the needs of the heart (Bruyninckx 2011). Hypoxia can be the result of three types of cardiac stressors:
V.S’s mother died in 2011, at the age of 73 from a myocardial infarction, and her father died at the age of 89, from complications from Alzheimer’s. Her husband passed in 2008; he lived through a ruptured aortic aneurysm, and then died from sepsis following a hernia surgery. She has 8 siblings, all living. She has three children (ages 30, 40, and 42) who are all healthy. She has five grandchildren, and one great grandchild. There is no known family history of hypertension, diabetes, or cancer. See genogram that follows…
Laboratory: CK 41, aldose 5.7, CCP 5, rheumatoid factor 10.8, ANA negative, ANCA is less than 1:20, P-ANCA less than 1:20, hypersensitivity pneumonitis panel is negative, anti-Jo-1 is less than 0.2, scleroderma antibody is less than 0.2, IDE total 5. CBC within normal limits.
A well-developed, well-nourished female in no distress seated comfortably in the exam room. We did review her chart. It does show a Tdap in October 2008. She did receive her seasonal flu vaccine in the past fall and she did have the Pneumovax in October 2011. I do not have records of any other vaccines including travel vaccines.
prescribed methylpredisone 4mg for 6 days and ibuprofen 600 mg PRN for pain. Her last
The purpose of this essay is to define public health and compare it to personal health, also a discussion of benefits and disadvantages of public health. The following questions will also be answered: What are the benefits of public health assessments? What are the disadvantages, if any? Give an example of a potential conflict within the community that could arise as a result of public health assessments. How can public health advocates and policy makers prevent and/or manage such a conflict? How can public health assessments be used to form public policy? Additionally, this paper will debate the how the community has or will be affected by the smoking in public places laws.
Family history: Mmother, alive at the age of 31, with a history of aplastic anemia, s/p liver and stem cell transplant after being diagnosed with fulminant
This report will discuss the health assessment of a client who presented to my PEP facility, Clinic 275. Clinic 275 is a confidential and complimentary walk-in sexual health service which provides medical consultation/advice, testing and treatment for sexually transmitted infections (STIs) (SA Health 2016a). Ultimately, this paper will illustrate how an ongoing health assessment, history taking, provision of client education and care options of certain STIs are fundamental to guiding the planning, implementation and evaluation of care for specific people. All information regarding the client, who will be referred to as R, was permitted for use by the facility and will maintain confidentiality in accordance with the guidelines of the Government of South Australia (2015, p.7; Nursing and Midwifery Board of Australia 2016).
Individual health practices and coping skills are those activities that people are able to employ with an aim of promoting health care, preventing diseases, solving certain problems, or developing self reliance. These factors are majorly lifestyle- related. This means that the personal health practices involve certain individual choices. It should be noted that these individual choices are mostly influenced by the social, environmental, and economic factors. In most cases, all these factors would be play within places where a person stays, grows, work, and/or learns. In today’s world, human kind is presented with a lot of choices to embrace. Some of these choices adversely affect the health condition of individuals.