Essay about Comprehensive Health Assessment

6001 WordsApr 7, 201225 Pages
COMPREHENSIVE WRITTEN ASSESSMENT 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
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