Rua- health history

by | Aug 30, 2023 | Uncategorized | 0 comments

creating a fake patient 

Example of this assignment is down below 

HEALTH HISTORY

DO NOT ALTER THIS FORM

Patient must be 35 years or older

Must follow HIPPA guidelines

Interview must be completed in person

BIOGRAPHIC DATA (2 points)

Name (Initials): Age: Gender: Marital Status:

Date of Birth: Birthplace:

Address (City/State only)

Race:

Religion/Culture: None is NOT an answer!

Occupation:

Insurance Coverage: Only need to know if they have health insurance – do not need policy name or number

Source of Information AND Reliability: ex: Patient and appears to be reliable

PRESENT HEALTH OR ILLNESS

Reason for Seeking Care: (“In quotes”) (2 points)

“I am helping (insert your name here) with their school project”


Present Health: (chronological account of
one
priority health issue) (3 points)

(This section will be how you address the ANALYSIS OF DATA on page 6)

Do this section last!

Chronological account – give a thorough history (like an OLDCART)

PAST HISTORY (10 points)

Childhood Diseases (age; measles, mumps, rubella, chickenpox, pertussis, strep throat, rheumatic fever, scarlet fever, poliomyelitis)

Ex: Measles early childhood (or their age, if they remember)

Denies all other diseases listed

Immunization Dates (influenza, pneumococcal, shingles; date of last tetanus; and date and results of last TB test)

If patient cannot recall the date, they can just provide an approximate date/age. For example: Patient states that they received their TB test within the last 5 years but cannot recall the exact date. Patient states that it was negative.

Accidents or Injuries (year; auto accidents, fractures, penetrating wounds, head trauma-especially if associated with unconsciousness, burns; complications)

Serious or Chronic Illnesses (asthma, depression, diabetes, hypertension, heart disease, HIV infection, hepatitis, sickle-cell anemia, cancer, seizure disorder;
year of diagnosis)

Hospitalizations (year; cause, name of hospital, doctor, how the condition was treated, how long the person recovered)

Surgeries (year; type of surgery, date, name of surgeon, name of

HEALTH HISTORY

DO NOT ALTER THIS FORM

Patient must be 35 years or older

Must follow HIPPA guidelines

Interview must be completed in person

BIOGRAPHIC DATA (2 points)

Name (Initials): Age: Gender: Marital Status:

Date of Birth: Birthplace:

Address

Race:

Religion/Culture:

Occupation:

Insurance Coverage:

Source of Information AND Reliability:

PRESENT HEALTH OR ILLNESS

Reason for Seeking Care: (“In quotes”) (2 points)


Present Health: (chronological account of
one
priority health issue) (3 points)

PAST HISTORY (10 points)

Childhood Diseases (age; measles, mumps, rubella, chickenpox, pertussis, strep throat, rheumatic fever, scarlet fever, poliomyelitis)

Immunization Dates (influenza, pneumococcal, shingles; date of last tetanus; and date and results of last TB test)

Accidents or Injuries (year; auto accidents, fractures, penetrating wounds, head trauma-especially if associated with unconsciousness, burns; complications)

Serious or Chronic Illnesses (asthma, depression, diabetes, hypertension, heart disease, HIV infection, hepatitis, sickle-cell anemia, cancer, seizure disorder; year of diagnosis)

Hospitalizations (year; cause, name of hospital, doctor, how the condition was treated, how long the person recovered)

Surgeries (year; type of surgery, date, name of surgeon, name of hospital, how person recovered)

Last Examination Date (physical, dental, vision, hearing, ECG, chest x-ray, mammogram, colonoscopy, serum cholesterol)

Allergies (allergan and reaction)

Current Medications (prescription and OTC;
name, dose, schedule)

FAMILY HISTORY (coronary artery disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle-cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, TB) (6 points)

Genogram (3 generations to in

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HEALTH 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

This study source was downloaded by 100000792604172 from CourseHero.com on 09-27-2022 14:53:34 GMT -05:00

https://www.coursehero.com/file/15013831/NR-302-RUA/

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HEALTH 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

Purpose

Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the individual through the collection of both subjective and objective data. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings. The purpose of the assignment is two-fold:

· To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and developmental) affecting health and wellness.

· To reflect on the interactive process between self and client when conducting a health assessment.

Course Outcomes: This assignment enables the student to meet the following course outcomes:

CO 1: Explain expected client behaviors while differentiating between normal findings variations, and abnormalities. (PO 1)

CO 2: Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of nursing process while obtaining a physical assessment. (POs 4 & 8)

CO 3: Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)

CO 4: Utilize effective communication when performing a health assessment. (PO 3)

CO 5: Demonstrate beginning skill in performing a complete physical examination, using the techniques of inspection, palpation, percussion, and auscultation. (PO 2)

CO 6: Identify teaching/learning needs from the health history of an individual. (POs 2 & 5)

CO 7: Explore the professional responsibility involved in conducting a comprehensive health assessment and providing appropriate documentation. (POs 6 & 7)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.



Total points possible: 100 points

Preparing the assignment

Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.

1. Complete a health assessment/history on an individual of your choice who is 18 years of age or older and NOT a family member or close friend.

a. The purpose of this restriction is to avoid any tendency to anticipate answers or to influence how the questions are answered. Your goal in choosing an interviewee is to s

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