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 will help identify the patient’s individual needs and concerns to build a nursing diagnosis, care plan, interventions, and then evaluate results to treatment implementations.
Date: November 29, 2011 Nurse: Karlyne Rubalcaba
Patient: R.M DOB: June 12, 1966 Civil Status: Married Birthplace: Havana City, Cuba
Chief Complaint & ID: Ms. R is a 45 y/o WF who has been having chest pains for the last week. Source: patient, who is reliable
Reason for Seeking Care: patient states “I came in today because I have pain in my chest and doesn’t let me breathe well” History of Present Illness: This is the first admission for this 56 year old woman, who states she was in her usual state of good health until one week prior to admission. At that time she noticed the abrupt onset (over a few seconds to a minute) of chest pain which she describes as dull and aching in character. The pain began in the left para-sternal area and radiated up to her neck. The first episode of pain one week ago occurred when she was working in her garden in the middle of day. She states she had been working for approximately 45 minutes and began to feel tired before the onset of the pain. Her discomfort was accompanied by shortness of breath, but no sweating, nausea, or vomiting. The pain lasted approximately 5 to 10 minutes and resolved when she went inside and rested in a cool area. Since that initial pain one week ago she has had 2 additional episodes of pain, similar in quality and location to the first onset episode. Three days ago she had a 15 minute episode of pain while walking her dog, which resolved with rest. This evening she had an episode of pain awaken her from sleep, lasting 30 minutes, which prompted her visit to Emergency Department. At no time has she attempted any specific measures to relieve her pain, other than rest. She describes no other associated symptoms during these episodes of pain, including dizziness, or palpitations. She becomes short of breath during these episodes but describes no other exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. No change in the pain with movement, no association with food, no GERD sx, no palpable pain. She has never been told she has heart problems, never had any chest pains before, does not have claudication. She was diagnosed with HTN 3 years ago. She does not smoke nor does she have diabetes. She was diagnosed with hypertension 3 years ago and had a TAH with BSO 6 years ago. She is not on hormone replacement therapy. There is a family history of premature CAD. She does not know her cholesterol level. -------------------------------------------------
Past Health History
Childhood Illnesses: chickenpox at age 7. No Measles, Croup, Whooping Cough (Pertussis), mumps. No Polio, Ear infections, Rheumatic fever, Scarlet fever, Impetigo, Kawasaki disease, Meningitis. Surgical:
1994: Total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids...