Health History Assessment
Name
Institution
Course
Instructor
Date
Health History Assessment
Introduction
Health assessment is an essential element in the nursing field and provides necessary information about a patient’s health. I will approach my client, a 41-year-old married male, and perform a head to toe examination. The assignment seeks to establish a nurse-client relationship. I was interested in the demographic data, patient perception of health, past medical history, and review of systems.
The Demographic Data
Mr. PC is a 42-year-old male, married to one wife, Mrs. AC, who is a housewife. The couple has three children. He is currently employed and works as a realtor. English is his primary language.
Perception of Health
The patient did not experience any form of pain nor discomfort at the time of assessment. However, he sometimes experiences severe headaches, chest pains, and breathing difficulties that go away after some time. The client struggles with weight issues and was recently diagnosed with hyperlipidemia.
Past Medical History
The patient has a medical history of hypertension and high levels of fats (hyperlipidemia). Apart from the two conditions, the patient has no other dragonized ailments.
Family Medical History
The patient’s parents are still alive with several medical conditions. His father was diagnosed with diabetes and hyperthyroidism. His father’s siblings also have a history of diabetes and hyperthyroidism. His mother has no medical history of severe disease, and her siblings, however, have a history of diabetes, hypertension, gout, and chronic lower back pain. PC’s paternal grandfather and grandmother were diagnosed with pancreatic and breast cancer, respectively. The patient’s spouse was diagnosed with hypertension and serious depression disorder. The patient’s children are all well with no serious medical conditions. His family therefore has a history of hypertension, diabetes, cancer and hypothyroidism.
Review of Systems
I conducted a full-body physical assessment on the patient. PC indicated that he is generally in good overall health. His weight, however, was significantly above the recommended. He has no history of respiratory, urinary, neurological, or cardiac illnesses. His eyes are equally reactive to light, and he has no record of cataracts. His throat and nose have no lesions nor bleeding. PC has no history of psychological disorders such as depression or anxiety.
Developmental Consideration
The aging stage that PC belongs to is middle adult age. The patient is at risk of developing diabetes and coronary heart disease from his medical history and health. His hypertension could increase many life-threatening severe disorders such as heart attacks, stroke, and kidney disease. The patient makes an average income and therefore has the challenge of feeling depressed and having other mental health problems.
Cultural Considerations
The patient is an American citizen of Caucasian descent. He has no history of migration to other countries. PC and his family have no cultural consideration as they abide by the Christianity religion.
Health history worksheet
Psychosocial Considerations
PC is at a high risk of developing mental health problems. His wife suffers from serious depression disorder, which has put a lot of strain on their marriage. His wife’s mental condition makes him very anxious and worried about his children’s future mental health, who depend on their mother for physical and moral support.
Collaborative Resources
The patient’s workplace is his first collaborative resource. He works five days a week and spends a more significant part of his days at work. According to him, he has made a lot of long-lasting friendships. His family, especially his parents, wife, and children, provide another critical resource to the client.
Conclusion
Health history assessment of PC helped me understand some of the underlying health risks of the patient. One of the challenges I faced while conducting the interview was that the client was reluctant to answer some of the questions, and he did not provide all the information relevant to this assessment.
Question
Bookstore
Library Guides
Media Gallery
My Media
New Webex
This assignment does not count toward the final grade.
Week 5: RUA: Health History
Due Friday by 9:59pm Points 100 Submitting a file upload
Download and review the Health History Guidelines (Links to an external site.) and Health History Worksheet (Links to an external site.) to gather and organize information when conducting the health history.
Submit the assignment as directed by your instructor.
See Calendar for due date information.
Rubric
NR302 RUA: Health History Guidelines (Sept20)
NR302 RUA: Health History Guidelines (Sept20)
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeHealth History Assessment
Required criteria
1. Demographics
2. Perception of Health
3. Past Medical History
4. Family Medical History
5. Review of Systems
6. Developmental Considerations
7. Cultural Considerations
8. Psychosocial Considerations
9. Collaborative Resources
70 pts
Highest Level of Performance
Includes 9 requirements for section.
66 pts
High Level of Performance
Includes 7-8 requirements for section.
52 pts
Satisfactory Performance
Includes 5-6 requirements for section.
35 pts
Unsatisfactory Performance
Includes 1-4 requirements for section.
0 pts
Not Present
No requirements for this section presented.
70 pts
This criterion is linked to a Learning OutcomeReflection
Required criteria
1. Reflect on your interaction with the interviewee holistically.
a) Describe the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.
2. How did your interaction compare to what you have learned?
3. What barriers to communication did you experience?
a) How did you overcome them?
b) What will you do to overcome them in the future?
4. What went well with this assignment?
5. Were there unanticipated challenges during this assignment?
6. Was there information you wished you had available but did not?
7. How will you alter your approach next time?
20 pts
Highest Level of Performance
Includes 7 requirements for section.
18 pts
High Level of Performance
Includes 6 requirements for section.
16 pts
Satisfactory Performance
Includes 5 requirements for section.
10 pts
Unsatisfactory Performance
Includes 1-4 requirements for section.
0 pts
Not Present
No requirements for this section presented.
20 pts
This criterion is linked to a Learning OutcomeStyle and Organization
Required criteria
1. Grammar and mechanics are free of errors.
2. Verbalizes thoughts and reasoning clearly.
3. Uses appropriate resources and ideas to support topic with APA where applicable.
10 pts
High Level of Performance
Includes no fewer than 3 requirements for section.
8 pts
Satisfactory Performance
Includes no fewer than 2 requirements for section.
4 pts
Unsatisfactory Performance
Includes 1 requirement for section.
0 pts
Not Present
No requirements for this section presented.
10 pts
This criterion is linked to a Learning OutcomeStyle and Organization
Required criteria
1. Grammar and mechanics are free of errors.
2. Verbalizes thoughts and reasoning clearly.
3. Uses appropriate resources and ideas to support topic with APA where applicable.
10 pts
High Level of Performance
Includes no fewer than 3 requirements for section.
8 pts
Satisfactory Performance
Includes no fewer than 2 requirements for section.
4 pts
Unsatisfactory Performance
Includes 1 requirement for section.
0 pts
Not Present
No requirements for this section presented.