Health Assessment
Abstract
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
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