NR 302 Health Assessment 1
Demographic Information
Patient A.B.L., a 26-year-old woman of Asian descent, was born on August 31, 1991, in Manila, Philippines. She and her family moved to the United States approximately 4 or 5 years ago and resided at 1234 N Whipcream Street, Chicago, Illinois. While Tagalog is her primary language, she is also fluent in English. A.B.L. is studying at Chamberlain College of Nursing and works as a server. She lives with her parents.
Patient A.B.L provided the following information herself and is alert and oriented times 4. She described herself as sociable but occasionally shy, emphasizing her diligent work ethic and sentimental nature. A.B.L. mentioned having a solid support system in her family and boyfriend, whom she relies on when facing challenges. Additionally, she enjoys spending 2-3 hours alone without feeling socially isolated. A.B.L. acknowledged experiencing mild but manageable stress and outlined her coping strategies: eating, shopping, sleeping, and working out at the gym. She stated, “I find these methods helpful for coping with and managing my stress.”
NR 302 Health Assessment 1
Perception of Health
In the discussion about health, I referred to the book “Physical Examination and Health Assessment” and asked A.B.L the following questions: “How do you define health?”, “How do you perceive your current situation?”, “What are your concerns?”, “What is your health goal?” and “What do you anticipate for the future?” (Jarvis, p.58). These questions served as a guide for both A.B.L and myself to facilitate her responses. As a student nurse, she has a conceptual understanding of health, but I encouraged her to provide her perspective. A.B.L. defined health as having a fully functional body that usually operates. She believes that good health is achieved when the body is functioning optimally. Currently, she does not express any specific concerns about her health, but her goal is to maintain her well-being in the long run.
Medical History
A.B.L. reported seeking care for a routine health check-up. She described her overall health as good and confirmed that she takes no medications. A.B.L. expressed her interest in physical activities such as working out 3-4 times a week, running, walking, and weightlifting. Regarding her medical history, A.B.L. disclosed a hospitalization during her childhood in the Philippines due to measles and a high fever. She denied any previous surgical procedures, operations, injuries, or car accidents. A.B.L. also mentioned having dust and excessive heat allergies, manifesting as an itchy nose and persistent sneezing when exposed. She reported receiving immunizations, including the flu shot, TB shot, Varicella shot, and TDAP, during her previous medical examinations. Additionally, she mentioned having undergone eye and dental check-ups last year.
NR 302 Health Assessment 1
A.B.L. reported no changes in weight through diet or other factors and denied experiencing fatigue, weakness, malaise, fever, chills, sweats, or night sweats. There were no indications of skin diseases such as eczema, psoriasis, or hives, and no noticeable changes in pigmentation, moles, dryness, moisture, itching, excessive bruising, rashes, or lesions. A.B.L. mentioned having a belly button piercing but no tattoos. Hair loss and changes in hair texture were not reported. Skin turgor appeared normal, indicating no signs of dehydration, and the skin was warm to the touch. Nails were smooth, clean, intact, and not brittle, with no changes in shape or color.
References
A.B.L. (2018, May 9). Health History. (J. Medulla, Interviewer) CDC. (2018). Gynecologic Cancers. Retrieved from Centers for Disease Control and Prevention:
https://www.cdc.gov/cancer/cervical/basic_info/screening.html
Go Red for Women. (2018). Causes and Prevention of Heart Disease. Retrieved from Go Red
For Women:
https://www.goredforwomen.org/about-heart-disease/facts_about_heart_disease_in_women-sub-category/causes-prevention/
Jarvis, C. (2016). Physical examination & health assessment. St. Louis, Mo.: Saunders Elsevier.
Link, R. (2018, March 5). 15 Incredibly Heart-Healthy Foods. Retrieved from Health Line.Red:
https://www.healthline.com/nutrition/heart-healthy-foods#section1
