Health Composite

Topics: Nicotine, Medical record, Smoking cessation, Pain / Pages: 11 (2719 words) / Published: Nov 2nd, 2013

Health Composite
Winston Salem State University

The author of this paper has performed a health assessment on an adult patient and will discuss the findings in this paper. The author will introduce the client, complete the health history, and physical exam. While summarizing the findings, the nursing diagnosis and the plan of care, will be discussed in order to help the patient achieve health goals.
Keywords: health history, nursing diagnosis, health assessment, adult, physical exam, plan of care
Patient: Helen Smith
5658 Purple Road
Mebane, North Carolina, 27302
Date of Birth: 11/2/1984
Birthplace: South Korea
Marital Status: Single
Source: Helen, reliable source
Reason for Seeking Care: General Physical Assessment
History of Present Illness: None, present for general physical assessment.

This is a 29 year old Asian female presenting for a general physical assessment. (Patient advised to follow-up with Primary Care Physician for more recent physical exam). The patient states no known complaints or illnesses at this time. The patient is a good health historian with appropriate interactions with examiner and staff. Ms. Smith will provide a reliable history for the examiner.

Medical History:
Childhood Illnesses: Patient had chicken pox prior to adoption, no history of measles, mumps, rubella, croup, or pertussis. No history of polio, rheumatic fever, or scarlet fever.
Accidents: None.
Chronic Illnesses: None.
Hospitalizations: None.
Obstetric History: Gravida 0/Para 0/Abortions 0
Immunizations: Childhood immunizations are up to date. Last tetanus: “college sometime.” Last TB skin test: “college sometime.”
Last Examinations: Yearly pelvic examinations; last physical exam at age 18, prior to college enrollment. Last vision test: April 2013, wears corrective lenses (glasses and contacts alternately). Never had EKG or chest x-ray.
Allergies: Penicillin, Amoxicillin,

References: Editor, Wissmann, J. (7.1 Ed.). (2007). Adult medical-surgical nursing, RN edition 7.1. USA; Assessment Technologies Institute, LLC. Jarvis, C. (2012) Physical examination & health assessment (6th ed.). Philadelphia: Saunders. Monahan, F. D., & Phipps, W. J. (2007). Phipps ' medical-surgical nursing: Health and illness perspectives. St. Louis, Mo: Mosby Elsevier. Wilkinson, J. M., & Ahern, N. R. (2009). Prentice Hall nursing diagnosis handbook with NIC interventions and NOC outcomes. Upper Saddle River, N.J: Pearson Prentice Hall.

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