NUR 220L HEALTH ASSESSMENT AND HEALTH PROMOTION LAB

Comprehensive Health History II*

*To be completed as Homework and submitted in Lab. Student will perform a Comprehensive Health History on an
adult/older adult who has a medical condition and taking prescribed medications.

Student Name: ___________________________________ Date: ___16/10/2020_____________

Biographical Data

Client’s Initials _____JK___ Gender____ F____ DOB___21/8/1937_____ Age_83_______

Race_______ African American __________

Marital Status___ Widowed_____ Nationality ___American_____ Culture ____African____ Primary Language

________English________

Religion___ Christian__________ Occupation ______Retired Nurse_________ Education_______ College _______

Sexuality ____ Heterosexual _________ Height______167 cm _____ Weight____130lbs_____BMI

_____24 (overweight) ____________

Source of Data___________Old CPMC chart_____________________ Reliability of Source__patient is reliable

_______________

Contact Person (Include relationship) ______Judy (Daughter) ___________________________________________

Reason for Seeking Healthcare / Chief Complaint: __Toothache like pain for 12
hours____________________________________________
_________________________________________________________________________________________

Current Health Status or History of Present Illness (For HPI use PQRST; For Pain use COLDSPA)

Precipitating / Palliative Factors hypertension Character chest pain

Quality / Quantity aching pain under Onset 12 hours
her breast bone
Location chest
Region / Radiation / Related Symptoms: chest pains
Duration on and off since 1995
Severity substernal toothache like chest pain
Severity 6 out of 10
Timing
Pattern sometimes the condition worsens with
medication
Associated Factors sometimes patient has dizziness
Current Medications (Dose, frequency, and reason): ___ Digoxin 0.125mg once daily, Enalapril 20mg twice daily

Fall 2018
Lasix 40mg once every other day, Kcl 20mg once daily, Tylenol 2 tabs twice daily as needed for arthritis
____________________________________________________________________________________________

Current Medical Diagnoses (Include dates of diagnosis): _____ Patient is diagnosed with hypertension in November
2018_________________________________________________
_______________________________________________________________________________________

Medication/Food/Environmental Allergies (Describe reaction that occurs if allergies exist): ______ Penicillin-developed
a diffuse rash after an injection 20 years ago________________________________________________________

Past Medical History

Childhood Illnesses: (Check all that apply)

Measles ______Mumps ______ Rubella ______ Chicken Pox______
Pertussis ______ Influenza _____Yes_ Ear Infections ______ Other ___________________

Previous Medical Conditions, Hospitalizations, Surgeries: ___ 1980 gastrointestinal hemorrhage, see below
3) 9/1995 chest pain- see history of present illness _______________________________
Accidents/Injuries: _________________________________________________________________
_________________________________________________________________________________

Travel Outside USA:

_______________NO________________________________________________
_________________________________________________________________________________
Immunizations: (Check all that apply)

Tetanus______ Rubella______ Pertussis______ Mumps______ Measles _______ Polio______

Hepatitis B______ Varicella______ Flu ___Yes___ Pneumonia ___Yes___ Other (Specify): ______________
Date of Last Examinations:

Physical Examination_10/12/20____ Vision__7/18/20____ Hearing __2/14/20___ Dental__6/20/20____

Female: PAP Smear____________ Mammogram__ Yes______ Breast ____Yes_____

LMP___________ Gravida_____ Para_____ Abortions_____ Miscarriage_________

Male: Prostate Exam____________ Testicular Exam ______________

Family History

 Document findings below and create genogram on the next page. Refer to page 53 in text .
 Include age and health issues. If deceased, indicate age and cause of death .

Mother and Father: _ mother died at the age of 51 from kidney failure; her father died
at the age of 45 in a car
accident_________________________________________________________________________________

Maternal Grandparents: No history__________________________________________________________

________________________________________________________________________________________
Fall 2018
 Fraternal Grandparents: No history__________________________________________________________
________________________________________________________________________________________

Parent’s Siblings: _____No record ___________________________________________________________

Client’s Siblings: _____No record ___________________________________________________________
Spouse/Significant Other/Partner: ____________________________________________________________
________________________________________________________________________________________
Children: She has 4 daughters (ages 60, 65, 56, 48) who are all healthy, and had a son who died at the age of 2 from pneumonia. She
has 12 grandchildren, 6 great grandchildren and 4 great, great grandchildren. There is no known family history of hypertension,
diabetes, or cancer._____________________

Genogram

Father
45 Mother
51

Kidney failure

Aunt

Fall 2018
Personal and Psychosocial History

Family and Social Relations: The patient is generally an alert and active woman despite her arthritic symptoms. She
understands that she is having a “heart attack” at the present time and she appears to be extremely anxious.
Diet/Nutrition: The patient does not follow any special diet or nutrition.
Activity/Exercise: The patient does not exercise
Sleep/Rest: The patient does not have enough rest or sleep
Oral Hygiene: The patient observers oral hygiene
Hobbies: Patient loves to cook, and to shop
Functional Ability (Check all that apply)

_Yes__Dressing _Yes__Toileting _Yes__Bathing _Yes__Eating _Yes__Ambulating _Yes___Shopping _Yes__Cooking

___Housekeeping

Personal Habits
Tobacco (show pack-year calculation) __No__ Alcohol ___No___ Recreational Drugs_No___
Health Practices (Frequency)
Physicals Exams _thrice a year___ Dental Exams _twice a year_ Eye Exams _every 3 years__

Human Violence ___Patient has not exposed to human violence. ________________________

Fall 2018
Review of Body Systems (Refer to pages 54 –65 in text for sample questions.)
General Health: Relatively good
Skin, Hair, Nails: Patient has skin discoloration, excessive dryness, rash, or lesion.
Denies any changes in shape, color, or dry brittleness of nails
Head and Neck: the patient has no any head injury, dizziness, or vertigo. The patient also denies
any limitation of motions, lumps or swelling
Eyes and Ears: Eyes: wears reading glasses but thinks vision getting is worse, no diplopia or eye pain
Ears: hearing loss for many years, wears hearing aid now
Nose, Mouth, Throat, Sinuses no epistaxis or obstruction, no history of tonsillitis or tonsillectomy
Wears full set of dentures for more than 20 years, works well.
Breast and Regional Lymphatics: atrophic and symmetric, non-tender, no masses or discharges.
Lungs: bibasilar rales. No dullness to percussion. Diaphragm moves well with respiration. No rhonchi,
wheezes or rubs.
Respiratory: No history of pleurisy, cough, wheezing, asthma, hemoptysis, pulmonary emboli, pneumonia,
TB or TB exposure
Cardiovascular: No history of claudication, gangrene, deep vein thrombosis, aneurysm. Has chronic
venous stasis skin changes for many years
Peripheral Vascular: Patient denies any peripheral vascular disease, varicose veins, swelling of
legs.
Abdominal/Gastrointestinal: Patient has no heartburn, nausea, vomiting, and change in bowel
habits or bowel texture.
Genito-Urinary/Sexual Health: Patient has no genital pain problems with testicular or urinary
complications. The patient also denies changes of urine color, or smell
Musculoskeletal: __the patient has no joint, muscle cramps, visible swelling.
Neurologic: _the patient has no experiences of seizures, fainting or stroke.
Hematologic: _the patient has lymph node swelling, excessive bruising, and bleeding tendency.
________________________________________________________________________________
Endocrine: __the patient has no history with diabetes, heat and cold intolerance, tumor.
________________________________________________________________________________
________________________________________________________________________________

Social Determinants of Health

Fall 2018
To what extent, if any, have the social determinants of health influenced the client’s current health,
wellness, and/or illness state?

Age: the patient agrees that her health condition is influenced by her age,
Gender: the patient agrees that gender is a social determinant of her health
Culture/Ethnicity: the patient suggests that her cultural beliefs make her delay medication and seeking
healthcare services.
Education _the patient’s health Literacy enables them make appropriate health decision
Physical Environment the patient lives in an urban environment by the highway making access to
healthcare facilities easier.
Access to Health Care and Social Services the patient has easy access to healthcare and social
services. Patient has primary and Dental care and many specialists close by

Risk Exposure The patient is not at risk of being exposed to toxins, smoke, or any hazardous being
affected on her current health.
Socioeconomic Status (Income/Employment/Insurance) the patient is retired and has Medicaid
insurance

Housing the patient says that she lives in a two-bedroom apartment with her daughter in a safe
neighborhood.

Employment and Working Conditions the patient says that she currently retired
Social Connectedness the patient in contact with friends and close to her family.

Fall 2018