1Running head: HEALTH HISTORY
Health History
Samantha Candela
Chamberlain College of Nursing
NR 302: Health Assessment
2/12/2016
Professor Moersch
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2HEALTH HISTORY
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
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3HEALTH HISTORY
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
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4HEALTH HISTORY
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.
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5HEALTH HISTORY
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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