RUA Reflection of The Health History Nursing NR302: Health Assessment I January 2023 /202, Exams of Nursing

Download RUA Reflection of The Health History Nursing NR302: Health Assessment I January 2023 /202 and more Exams Nursing in PDF only on Docsity! RUA Reflection of The Health History Nursing NR302: Health Assessment I January 2023 /2024 Best Version pg. 1 [Document title] HEALTH HISTORY ASSESSMENT 2 Data Collection Date: 01/07/2020 Client Initials: M. C. Gender: Female Birth date and Month: 01/25 Marital status: Single Race: Caucasian Date of last physical exam: Patient States her “last physical was in March of 2019.” Primary Language: English Occupation: Practice Manager of an Urgent Care Source of Information: Patient REASON FOR SEEKING CARE Patient has come to Chamberlain Hospital seeking care for “consistent diarrhea.” PRESENT HEALTH/HISTORY OF PRESENT ILLNESS PALLIATIVE/PROVOCATIVE: Patient states “nothing helps my upset stomach.” Patient states “my stomach is more upset after eating.” QUALITY: Patient states “there is a constant dull pain in my lower stomach and my stool is sometimes green not brown.” REGION/RADIATING: Patient states her pain “is in the lower left side of her stomach and her middle back area.” SEVERITY: pg. 2 HEALTH HISTORY ASSESSMENT 5 Grav 0 Term 0 Preterm 0 Ab 0 Living 0 Medications Name the Drug Dosage/Frequency Reason Vitamin B-12 1 shot IM/Monthly Manage Energy Level Skyla Intrauterine Device (IUD) Prevent Pregnancy Allergies to medications Name the Drug Reaction You Had Bactrim Skin rash and vomiting REVIEW OF SYSTEMS BODY SYSTEM General Patient presents with fever, chills and sweats. Patient denies weight gain or weight loss. Skin, Hair, Nails Patient denies rashes, lesions, history of skin diseases, and excessive dryness or moisture. Eyes, Ears, Nose, Mouth, Throat, Neck Patient denies eye pain and sinus pain. Patient presents with dry mouth and neck pain. Breasts Patient denies breast pain, rashes, nipple discharge and history of pg. 5 HEALTH HISTORY ASSESSMENT 6 breast disease. Respiratory Patient denies chest pain with breathing, shortness of breath, cough, and history of lung disease. Cardiovascular Patient denies pressure, tightness, palpitations, and history of heart disease. Peripheral Vascular Patient denies coldness, numbness, tingling, and discoloration of hands and feet. Gastrointestinal Patient presents with decrease in appetite, diarrhea, nausea, and pyrosis associated with eating. Patient denies history of abdominal disease. Urinary Patient presents with flank pain, cloudy urine, decrease in urination. Patient denies pain in groin and history of urinary disease. Reproductive Patient denies discharge, vaginal itching, intermenstrual spotting. Last menstrual period 12/20/2019-12/26/2019. Last Gynecologic appointment 05/2019. Last Pap test 05/2019. Musculoskeletal Patient presents with weakness in muscles. Patient denies limitation of motion, history of gout, and arthritis. Neurological Patient denies tremors, paralysis, history of mental health, and coordination problems. FAMILY HISTORY Provide an Overview for: Alcohol or drug addiction Father Tobacco use Father Allergies Mother (Bactrim) Arthritis Father and Mother Asthma N/A pg. 6 HEALTH HISTORY ASSESSMENT 7 Cancer: breast, colorectal, ovarian, other type of cancer Father (Skin) Coronary heart disease N/A Diabetes N/A High blood pressure Father and Mother Kidney disease N/A Mental Illness Dad and Brother (ADD) Obesity N/A Seizure Disorder N/A Sickle cell anemia N/A Stroke N/A Suicidal ideation N/A Tuberculosis N/A FUNCTIONAL ASSESSMENT AND ADLS Provide an Overview for: Self-Concept: Patient is in college, practices Christianity. Adequate income for lifestyle. Activity and Exercise: Patient independent with activities of daily living (ADLs). Sleep and Rest: Patient denies sleep aides. Sleep patterns are regular. Nutrition and Elimination: Patient denies food allergies. Bowel elimination is increased from 1 time a day to 5 times a day. Patient uses assistance of Imodium to decrease diarrhea. Perception of Health: Patient states health as being “happy and secure, with little to no pain within the body.” “I use exercise to maintain my overall health mentally and physically.” Intimate partner violence: Patient denies intimate partner violence. pg. 7 HEALTH HISTORY ASSESSMENT 10 knowledge in nursing school is what we are expected to use to demonstrate skills assessment and care for our patients. One piece of information I wish I would have obtained in my assessment would be, exactly what did my patient eat at her hibachi dinner and not just the vague response of what type of food. Patient responses are often simple and vague, this is why using open ended questions are important for collecting all information needed for the assessment. Follow up questions would have been useful such as, “can you recall what was in the meal that you ate” Did anyone else eat the same thing and also get sick?” Having this little bit more of information could be crucial for my patient’s assessment. I feel that in the future when performing an assessment, barriers experienced in this assignment will be altered to better my performance for future patients. Specifically, not allowing distraction of other students. Also, to better pretend that who I am assessing I have never seen before, allowing demonstration of my best performance as a student nurse and to better my preparation for future courses. Conclusion As a nurse assessment is something that is always being done. When taking care of patients, you will experience fluctuation in stability always leaving opportunity for further assessment. The health history is not only important for ill patients but for any patient in general. Evaluation of outcomes regarding a person’s health is done through critical thinking in order to examine our practice and thinking when assessing and interacting with patients. pg. 10 HEALTH HISTORY ASSESSMENT 11 References Jarvis, C., & Eckhardt, A. (2020). Chapter 4 The Complete Health History. (8th), Physical Examination & Health Assessment (pp. 45-62). Canada: Elsevier. pg. 11