Introduction Every patient that comes in seeking medical attention, has had a health history assessment conducted on them. Such an assessment provides health care workers such nurses, with vital information about the patient’s overall well-being. It can also be viewed as a guide in directing the nurse, in provided the most beneficial and utmost plan of care. The purpose of this paper is to exemplify a conducted health history assessment on a patient represented by the initials L.H.; Which focuses on subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings. Demographic Data Patient L.H. is a 69-year-old married Caucasian male that is a retired teacher that lives at home with his …show more content…
Family Medical History L.H. is the youngest child, by his deceased parents. His father died of a heart attack at the age of 62; while his mother passed away at 88 years old from chronic leukemia. L.H brother is alive and well. Currently, L.H wife is current 68 and is healthy, with the same for their son who, is 40 years old. Review of the Systems The general health of the patient is currently being compromised due to present illness mentioned above, but is stable. L.H. reports his usual health to be, “normal and not too crazy like this”. Patient has some fatigue noted while conducting daily activities; No recent weight change, fever or sweat. The skin noted to some discoloration on upper right side of back. There is no pruritus, rash or lesions present. Bruises noted bilateral on arms. Patient reported taking baby aspirin as daily medication. His hair is greying and thinning with no hair loss. L.H. report no concurrent or severe headaches; There was no head trauma, syncope or vertigo. Patient wears corrective lens with no difficulty of vision or diplopia; absent of inflammation, discharge or lesion. Last eye exam was in September of 2016 with no history of glaucoma, cataracts. L.H. denies having any frequent colds, sinusitis, epistaxis and trauma. Patient reports having obstruction stating, “it happens when I am lying down” with an occasional postnasal drip. The patients mouth and throat are absent of any pain,
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PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.
Health history assessment conducted on George on the fifteen of February 2010 at approximately one o’clock. George is a fifty-four year white male married with three adult children and two grand children. He has been working as a teacher for over twenty years a local middle school. This paper will highlight George’s health care issues and will identify five nursing diagnosis for him.
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
Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.
A is an 87 year old women, with a long history of health troubles including chronic kidney disease, congestive heart failure, coronary artery disease, a pacemaker insertion for her atrial fibrillation, type 2 diabetes, dyslipidemia, colon cancer, breast cancer, mild cognitive impairment and most recently paranoid psychosis.
In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.
As you learned in NR302, before any nursing plan of care or intervention can be implemented or evaluated, the nurse conducts an assessment, collecting subjective and objective data from an individual. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting both subjective and objective data, synthesizing the data, and identifying health and wellness priorities for the person. The purpose of the assignment is twofold.
The resident is an 88-year-old Caucasian male who has been married for 63 years along with a long-term care living arrangement. He has medical diagnoses of generalized muscle weakness, cutaneous abscess of buttocks, and lack of coordination. The resident rated his health status as a score of “7” because he stated that he felt pretty energetic most of the time.
Demographics: Patient is a 32-year-old, moderately built Caucasian female; separated once with 2 children. She lives with her children in her mother’s town house in the North-eastern part of the province. She is currently unemployed and receiving disability from the state from sustained back injury. She has Medicaid insurance; speaks English and practices the Baptist religion.
Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.
Patient, Sarah, is a 19 year old African American female. Sarah has been employed at two different McDonalds over the past four years. She is in a heterosexual relationship and three months pregnant.
Demographic Data: Mrs. BM, a 35 year old African American Female, comes to the health center for annual physical assessment. Mrs. BM is employed as a sales assistance in a grocery store and an undergraduate nursing student in Chamberlain college of Nursing. She has an insurance through her employer which covered her dental, eye and medical care. She lives in an apartment in Richmond Avenue, Texas. Mrs. BM lives with her husband whom is named as her emergency contact, and her three children, age 12, 8 and 6. Mrs. BM was born in November 12th 1981 in Houston Texas. She speaks, reads and write English. Mrs. BM has immediate family members, who also lives in Richmond Texas. She has a bachelor degree in sales management in Houston Community College
The major purpose of taking patients’ health history is to set the preliminary for the practitioner to enabling them to explicitly diagnose the patient’s health problem and also give their consideration to the patient’s social, psychological, and behavioral background (Celia, 2013). The process of taking a comprehensive health history is considered as the most significant aspect that allows patients to provide their concern of their present illness including symptoms, their current perceives and management of illness to the health practitioners, and the procedure is progressively being undertaken by nurses (Lloyd & Craig, 2007). According to Jarvis (2012) taking the interview for history healthcare assessment is the very first important part