Health History
Samantha Candela
Chamberlain College of Nursing
NR 302: Health Assessment
2/12/2016
Professor Moersch
Health History Assessment
I choose to do a health assessment on a family friend. I will use AH has her initials.
Demographic Data
AH is 63 years old, a female, Caucasian, and lives in a house. She lives in a rural area where she lives alone but has family close by.
Perception of Health
To her healthy means being in good health, getting regular exercise, and eating nutritious food. Unhealthy to her means not being in good health, overweight, and eating bad foods. She feels like she is between healthy and unhealthy. She is not in the best health, exercises once a week, and eats good most of the time. She would like to increase her health and the amount of exercise she gets.
Past Medical History
Her past medical history includes degenerative disc disease, high blood pressure, hyperlipemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis. Her past surgical history includes neck and back surgery, removal of gallbladder, removal of cataract, and hysterectomy. The medications she takes daily include a Spiriva inhaler, allegra, valium, Zoloft, gabapentin, Lopressor, and protonix.
Family Medical History
Both of her parents had high blood pressure, which lead to her high blood pressure. Her mother had asthma, which increased her chance of having it. Her father had lung cancer from smoking cigarettes. Her mother was anemic and had to have a lot of blood transfusions.
Review of Systems
The only skin issue that she has is eczema. Her hair has some grey in it and her nails are fine. She doesn’t have any headaches, head injury, or dizziness. She has some pain in her neck when she turns her head to the right. She doesn’t have any lymphatic issues. She has decreased vision and had some cataracts. She wears eyeglasses and had cataract removal surgery in June 2015. She doesn’t have any earaches or infections and her hearing is good. She has allergies to pollen and dust but no other major sinus issue. Her mouth and throat look good, no mouth pain, sore throat, toothaches, or lesions. She has asthma and emphysema, which causes her to have shortness of breath. Even with her breathing problems she can still take care of herself, cook, and clean. Her only heart related use is high blood pressure and she controls that with medication and controls her salt intake.
Developmental Considerations
She has had asthma since she was a little girl and this has caused her some issues growing up. She couldn’t play sports and play with friends for long because she would start having trouble breathing. She did not have many friends growing up and had trouble with weight; she always thought that her asthma caused this.
Cultural Considerations
Growing up she was always interested in going to church but her family wasn’t very religious. She always wanted to study her bible and her father would always have mean comments to say to her. This made it hard for her to go to church and be able to have a religious connection.
Psychosocial Considerations
She lost her husband almost a year ago and has had trouble with wanting to be social. She doesn’t like to attend social events because that was something her and her husband always used to do together. Her children are great about coming to visit her. At least one of them comes by daily and they have a weekly family night.
Collaborative Resources
Her family helps her by visiting everyday and going to any doctor appointments with her. She has a group of friends that go to church every Sunday together then go to lunch afterward. Her neighbor and her get together a few days of the week and walk to get exercise.
Reflection
This interaction helped me to practice some of the skills I learned in health assessment. We were able to talk about her medical history well since I know a lot of the medical terms and she also does because of how much she has had to be at hospitals. During the review of systems she had trouble understanding some of the questions I asked but we overcame it by me explaining each subject. I now realized I should have asked her more about any cultural issues.
References
American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.
Jarvis, C., Tarlier, D., Pelt, L. V., Andrews, M. E., & Jarvis, C. (n.d.). Physical examination and health assessment (7th ed.).
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