Health Composite: A Case Study
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Health Composite
Winston Salem State University
Abstract
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 …show more content…
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, Azithromax.
Current Medications: Multi-vitamin daily, low-estrogen type birth control, 1/day, for 13 years. Ibuprofen po prn headaches, Tums po prn indigestion, OTC Lactaid po prn.
Family History: Patient was adopted at the age of 8 months and there is no known family history.
Genogram:
Psychosocial: Patient currently lives with mother and works fulltime in a real estate office. Never married. Has lived in NC since age of 8. Sleeps well, 8-10 hours per night. Cigarette use and occasional alcohol
Health Composite
Winston Salem State University
Abstract
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 …show more content…
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, Azithromax.
Current Medications: Multi-vitamin daily, low-estrogen type birth control, 1/day, for 13 years. Ibuprofen po prn headaches, Tums po prn indigestion, OTC Lactaid po prn.
Family History: Patient was adopted at the age of 8 months and there is no known family history.
Genogram:
Psychosocial: Patient currently lives with mother and works fulltime in a real estate office. Never married. Has lived in NC since age of 8. Sleeps well, 8-10 hours per night. Cigarette use and occasional alcohol