NR302 Health Assessment 1

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Running Head: HEALTH HISTORY 1

Health History

Daniel Pompa

Chamberlain College of Nursing

NR 302 Health Assessment I

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HEALTH HISTORY 2

Demographic Data

L.S. is a 23-year-old Caucasian woman born on February 4, 1993, in Baltimore,

Maryland. Primary language is English with a slight understanding of Spanish. Graduated High

school in 2011 and currently goes to school in Salisbury, while working as veterinary

receptionist/ technician. Now lives with her boyfriend and his parents until she gathers enough

income to move out. Pt reports having frequent headaches.

Health Perception: Pt states, "I'm aware that I am obese, but I have been watching what I

eat and have been frequently running to prepare myself for an upcoming marathon." Pt considers

herself overweight, but in over all good health, she is very health conscious now that she will be

running a marathon in a few months.

Past Medical History

L.S. does not smoke but has occasional drinks on the weekends when off from work. L.S.

has never been hospitalized for anything major but has been diagnosed with shin splints, when

she was very active playing soccer in High School. Takes 200mg Ibuprofen when headaches

arise.

Family History

Paternal grandparents are both living, high school graduates, grandfather is a retired

Firefighter, who was diagnosed with diabetes at age 73 and had a heart attack at 75.

Grandmother is retired and in overall good health but had spinal surgery on 2015. Maternal

grandparents are deceased, high school graduates. Grandmother had a history of poor circulation,

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HEALTH HISTORY 3

smoked until aged 25, died of lung cancer. Grandfather, a Navy Seaman, was a heavy drinker,

passed away with bladder and prostate cancer. Pt mother, Bachelor's Degree, IT Manager at US

Census Bureau, no major health Concerns. Sibling: Brother sustained Heart attack at 41,

diagnosed with colon and liver cancer at 58. Father, Bachelor's degree, IT Specialist with DOD,

hypertensive, obese, pre-diabetic, migraines and chronic sinusitis. Sibling: Brother, Diabetic type

Review of Systems

All systems reviewed. Noted abnormalities: BP elevated at 122/88, Pt was anxious, acne

on Rt side of the face, comedones on Rt and Lt side of the nose. Developmental Considerations:

Pt seems reliable providing original data congruent with previous statements. Cultural

Considerations: No significant considerations with this pt. Psychosocial Considerations: Pt's

speech, behavior, mood, alertness, appearance and cognitive functions are appropriate. No

special considerations needed. Collaborative Resources: The Obesity Society website: Fact

Sheets, American Diabetes Association: Diabetes Basics, Food & Nutrition.

Reflection

In all the interview process was absorbing and insightful. The meeting took place at a

local coffee shop, which was very low key and quite enough to get comfortable. L.S. chose this

location because it was her favorite place to get away and do her school work, so she was very

calm and willing to answer any question. It was a little nerve-wracking at first, but having my

questions well thought out and using what we have learned in class made things go smoothly

throughout the process. Before the interview began, we did talk about ourselves over a cup of

coffee, which made the Pt relaxed and more willing to trust me. The Pt, being able to trust me

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HEALTH HISTORY 4

was easier on my part, she had no barriers that needed to be addressed, which was great, but I

will need to know that this will not always be the case. There was not much more information

that I needed to get from the PT, but for future purposes, I will try and not ask a closed-ended

question as much as I did. After the interview questions were over, I referred the Pt to obtain

more information and inform herself about the effects of diabetes and Nutritional values. L.S.

seemed very interested to learn more about these topics since she could very well be a diabetic in

her future years.

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HEALTH HISTORY 5

Health History Worksheet

This worksheet is used to assist the student in gathering and organizing information when conducting a health history.

Family Member Description Paternal grandfather

First and last initials: RS

Birthdate: May 26 1940 Death date: N/A Occupation: FireFighter-Retired Education: Highschool Diploma Primary language: English Health summary: Heart attack at 75 years, Diabetic at 73

Paternal grandmother First and last initials:

Birthdate: 1943 Death date: N/A Occupation: Retired Education: High School Diploma Primary language: English Health summary: Spinal surgery 2015, no other health problems.

Father First and last initials:

Birthdate: October 17 1964 Death date: N/A Occupation: IT Specialist with DOD Education: Bachelor’s Degree Primary language: English Health summary: High BP, Obesity, pre-diabetic, migraines, Chronic Sinusitis

Father’s siblings- Summary of any significant health issues

Brother- Diabetic type 2

Maternal grandMother First and last initials:

Birthdate: N/A Death date: September 2011 Occupation: Stay home mom Education: High school Primary language: English Health summary: Poor circulation, Smoker until age 25, died of lung cancer

Maternal grandFather First and last initials:

Birthdate: N/A Death date: December 2013 Occupation: Navy Soldier Education: High school Primary language: English Health summary: Heavy drinker, Died with bladder and prostate cancer

Mother First and last initials:

Birthdate: Jan 15 1965 Death date: N/A Occupation: IT Manager at US Census Bureau

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HEALTH HISTORY 6

Education: Bachelor’s Degree Primary language: English Health summary: No major health problems

Mother’s siblings- Summary of any significant health issues

Brother- Colon and Liver cancer at 58, Heart attack at 41

Adult Participant First and last initials:

Birthdate: Feb 4 1993 Death date: N/A Occupation: Veterinary Receptionist/Technician/Student Education: Some college Primary language: English Health summary: Obese, frequent headaches

Adult participant’s siblings Summary of any significant health issues Adult participant’s spouse/significant other

First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Adult participant’s children- Up to 4 children Child #1 first and last initials:

Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #2 first and last initials:

Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #3 first and last initials:

Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #4 first and last initials:

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HEALTH HISTORY 7

Birthdate: Death date: Occupation: Education: Primary language: Health summary:

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