Health Assessment Essay - 4586 Words

Abstract Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that†¦show more content†¦Stopped after 6 months because of drowsiness. 1990: Diagnosed with peptic ulcer disease, which resolved after three months on cimetidine. She describes no history of cancer, lung disease or previous heart disease. Allergy: Penicillin; experienced rash and hives in 1985. Social History Alcohol use: 1 or 2 beers each weekend; 1 glass of wine once a week with dinner. Tobacco use: None. Medications: No prescription or illegal drug use. Occasional OTC ibuprofen (Advil) for headache (QOD). Accidents or Injuries: No automobile accident. Immunizations: Childhood immunizations up to date. Last influenza, â€Å"probably 2 years ago†. No TB skin test. Last Examinations: Last examination 2 weeks ago, general check up, told â€Å"normal†. Yearly clinical breast examination (CBE), mammography, told â€Å"normal†. Yearly Pap smear, last performed January last year, 2010. Last visit to oncologist, 2008, told â€Å"normal†. Current medications: Prescribed Antacids, Nexium, q24h, or when pain is severe, Tylenol 500 mg, PO, q12h. ------------------------------------------------- Family History R.M is the first youngest child, two sisters, healthy, parents married, father had chronic alcoholism, mother remains in perfect general health, not known disease or condition. Grandmother on father’s side T.E, died at age 78, from cardiac arrest; Grandfather on father’s side, R.M, died at age 45, from automobile accident; Grandmother on mother’s side, L.S, suffered from Parkinson, died at age 79,Show MoreRelatedAssessment Of A Nursing Health Assessment1895 Words   |  8 PagesWhat is assessment? Assessment in nursing has been influenced by the problem-solving framework of the nursing process and nursing models. Assessment of need is fundamental to the care process and has received much attention in correspondence to the establishment of eligibility criteria for long-term care (RCN, 2004). 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