Comprehensive Health Assessment Paper

Topics: Nursing, Health care, Medical record Pages: 7 (1726 words) Published: March 15, 2015
A Comprehensive Health Assessment of M. H.
Nicole M. Henneberg
Empire State College

The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient's complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained through inspection, palpation, percussion, and auscultation techniques. The case study results are interpreted from the perspective of a registered nurse, and three nursing diagnoses are identified. Biographic Data

M. H. is a 63-year-old married white female. She is currently unemployed for four months. Her most recent employment of seven years was as a private home health aid for a friend's elderly parents who have since passed away. She was born in Buffalo, New York into a family of German decent. She currently lives in a suburb of Buffalo, N. Y. English is her primary language. Culture and Spirituality

M. H. was raised in a traditional German family where her father was the head of the household. However, her father and mother made many decisions mutually and shared household chores (Purnell, 2014). Her father was an Air Force pilot during World War II, and then worked as a chemical engineer until retirement. The household atmosphere was loving and respectful. She and her five siblings were brought up as Roman Catholics. They were expected to be polite, use table manners, be on-time to meals, respect their elders, do as they were told, share, finish their chores before recreating, get good grades in school, pray before meals and at bedtime, and attend church every Sunday and on holy days (Purnell, 2014). Past Health History

When she was a child, M. H. did not have any serious illness, nor does she have any chronic illnesses currently. She did, however, have a severe case of chickenpox when she was about 3-years- A COMPREHENSIVE HEALTH ASSESSMENT OF M. H. 3 old, and shingles about 18 years ago. M. H. has not been in any major accidents or had any life-threatening injuries during her life. She has been hospitalized two times for childbirth. Her obstetric history includes Gravida 2/Term 2/Preterm 0/Abortion 0/Living 2. Both births were uncomplicated vaginal deliveries. Surgical history includes tubal ligation at age 24, and removal of benign cysts in her left breast, left cheek, and left wrist between the years 1998-2003. All of her childhood vaccinations are up to date. She gets vaccinated for influenza almost every year, but she did not get vaccinated this season. She received the varicella zoster virus vaccine in February, 2015; no reactions noted. Her last tetanus shot was more 10 years ago. She denies ever having been exposed to tuberculosis (TB), and nor has she ever had a TB skin test (Jarvis, 2012).

M. H. sees her primary physician every year for a physical. Her last physical was in February, 2014. She also sees her dentist annually for a check-up and cleaning. She is currently scheduled for April, 2015. As a child she never needed corrective lenses, but for the last 15 years she has needed glasses for reading. Therefore, her vision is checked annually, most recent appointment having been in January, 2015. Because she has a history of benign cysts in her breast tissue, she gets a mammogram every five years. Her last mammogram was in 2010. Results of her Pap tests have never been abnormal. She cannot recall the date of her last gynecological exam. She also gets a coloscopy every couple of years,...

References: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nurse 's pocket guide: Diagnoses, Prioritized Interventions, and Rationales (12th ed.). Philadelphia, PA: F. A. Davis Company.
Jarvis, C. (2012). Physical Examination and Health Assessment (6th ed.). St. Louis, MO: Elsevier.
Purnell, L. D. (2014). Culturally Competent Health Care (3rd ed.). Philadelphia, PA: F. A. Davis Company.
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