NUR2092 WRITE-UP\u2014HEALTH HISTORY Classroom Assignment Week Two
\nDate ___4\/16\/22____________ Examiner _ __________
\n1. Biographic Knowledge Title: ___ _____________________________________ Phone_________________ Address__ Il_________________ Birthdate ________________________________ Birthplace ______ ________ Age __37________ Gender _____Male_____ Marital Standing _Married _____________ Occupation __Independent Contractor________ Race\/ethnic origin __ _____________________ Employer __ __________________
\n2. Supply and Reliability: From Affected person<\/p>\n
three. Cause for Searching for Care: Annual medical check-up<\/p>\n
four. Current Well being or Historical past of Current Sickness: None<\/p>\n
Previous Well being
\nDescribe basic well being __Good____________________________________________________ Childhood diseases ____None____________________________________________________________ Accidents or accidents (embrace age) ___None________________________________________________ Critical or persistent diseases (embrace age) _None______________________________________________ Hospitalizations (what for? location?) ___None_______________________________________________ Operations (identify process, age) _____None_______________________________________________ Obstetric historical past: Gravida __N\/A__________ Time period ___N\/A_________ Preterm ___N\/A_________ (# Pregnancies) (# Time period pregnancies) (# Preterm pregnancies) Ab\/incomplete _N\/A____________________ Kids residing _____N\/A________________ (# Abortions or miscarriages) _N\/A____
\nCourse of pregnancy____N\/A____________________________________________________________ (Date supply, size of being pregnant, size of labor, child\u2019s weight and intercourse, vaginal supply or cesarean part, issues, child\u2019s situation) Immunizations: _Up to this point immunization____________________________________________
\nFinal examination date: Bodily ________________
\nDental ____9\/_14\/2021___________ Imaginative and prescient __11\/17\/2021________ Allergic reactions __None____________ Response ___None_________________________<\/p>\n
Present drugs ___None___________________________________________ _
\n6. Household Historical past\u2014Specify Which Relative(s)
\nCoronary heart illness: _None_______________________ Hypertension: _Father_____________
\nStroke: _Father______________________ Diabetes: ___None ____________________________
\nBlood problems: _______None _______________ Breast or ovarian most cancers: ____None________
\nMost cancers (different): ____None______________________ Sickle cell: __None __________________
\nArthritis: ____None_____________________ Allergic reactions: ____None___________________________ Bronchial asthma: None __________________
\n____ Weight problems: ___None____________________________ Alcoholism or drug habit _None _____________
\nPsychological sickness _None____________________ Suicide ___None____________________________
\nSeizure dysfunction __N\/A______________________ Kidney illness __N\/A________________________ Tuberculosis _N\/A____
\nOverview of Programs (Circle\/spotlight each previous well being issues which were resolved and present issues, together with date of onset.)
\nBasic General Well being State: Current weight (achieve or loss, time period, by weight loss program or different elements), fatigue, weak point or malaise, fever, chills, sweats or night time sweats. None
\nPores and skin: Historical past of pores and skin illness (eczema, psoriasis, hives), pigment or colour change, change in mole, extreme dryness or moisture, pruritus, extreme bruising, rash or lesion: None
\nHair: Latest loss, change in texture: None
\nNails: Change in form, colour, or brittleness: None
\nWell being Promotion: Quantity of solar publicity, methodology of self-care for pores and skin and hair: N\/A
\nHead: Any unusually frequent or extreme headache, any head damage, dizziness (syncope), or vertigo: None
\nEyes: Issue with imaginative and prescient (decreased acuity, blurring, blind spots), eye ache, diplopia (double imaginative and prescient), redness or swelling, watering or discharge, glaucoma or cataracts: None
\nWell being Promotion Eyes: Wears glasses or contacts, final imaginative and prescient test or glaucoma take a look at, how dealing with lack of imaginative and prescient, if any: None
\nEars: Earaches, infections, discharge and its traits, tinnitus, or vertigo: None
\nWell being Promotion Ears: Listening to loss, listening to support use, how loss impacts day by day life, any publicity to environmental noise, methodology of cleansing ears: None<\/p>\n
Nostril and Sinuses: Discharge and its traits, any unusually frequent or extreme colds, sinus ache, nasal obstruction, nosebleeds, allergic reactions or hay fever, or change in sense of odor: None
\nMouth and Throat: Mouth ache, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered style: None
\nWell being Promotion\/Mouth & Throat: Sample of day by day dental care, use of prostheses (dentures, bridge), and final dental checkup: None
\nNeck: Ache, limitation of movement, lumps or swelling, enlarged or tender nodes, goiter: None
\nBreast: Ache, lump, nipple discharge, rash, historical past of breast illness, any surgical procedure on breasts Axilla: Tenderness, lump or swelling, rash: N\/A
\nWell being Promotion Breast: Performs breast self-examination, together with frequency and methodology used, final mammogram and outcomes: N\/A
\nRespiratory System: Historical past of lung illness (bronchial asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest ache with respiratory, wheezing or noisy respiratory, shortness of breath, how a lot exercise produces shortness of breath, cough, sputum (colour, quantity), hemoptysis, toxin or air pollution publicity Well being Promotion Respiratory: Final chest x-ray examination: None
\nCardiovascular System: Precordial or retrosternal ache, palpitation, cyanosis, dyspnea on exertion (specify quantity of exertion it takes to provide dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, historical past of coronary heart murmur, hypertension, coronary artery illness, anemia
\nWell being Promotion Cardiovascular: Date of final ECG or different coronary heart exams and outcomes: None
\nPeripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, exercise), discoloration in fingers or toes (bluish crimson, pallor, mottling, related to place, particularly round toes and ankles), varicose veins or issues, intermittent claudication, thrombophlebitis, ulcers Well being Promotion Peripheral Vascular: If work entails long-term sitting or standing, keep away from crossing legs on the knees; put on help hose. None
\nGastrointestinal System: Urge for food, meals intolerance, dysphagia, heartburn, indigestion, ache (related to consuming), different belly ache, pyrosis (esophageal and abdomen burning sensation with bitter eructation), nausea and vomiting (character), vomiting blood, historical past of belly illness (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel motion, any latest change, stool traits, constipation or diarrhea, black stools, rectal bleeding, rectal circumstances, hemorrhoids, fistula)
\nWell being Promotion Gastrointestinal: Use of antacids or laxatives: None
\nUrinary System: Frequency, urgency, nocturia (the variety of instances awakens at night time to urinate, latest change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine colour (cloudy or presence of hematuria), incontinence, historical past of urinary illness (kidney illness, kidney stones, urinary tract infections, prostate); ache in flank, groin, suprapubic area, or low again: None
\nWell being Promotion Urinary: Measures to keep away from or deal with urinary tract infections, use of Kegel workouts: None
\nMale Genital System: Penis or testicular ache, sores or lesions, penile discharge, lumps, hernia: None
\nWell being Promotion Male Genital: Carry out testicular self-examination? How incessantly? None
\nFeminine Genital System: Menstrual historical past (age at menarche, final menstrual interval, cycle and length, any amenorrhea or menorrhagia, premenstrual ache or dysmenorrhea, intermenstrual recognizing), vaginal itching, discharge and its traits, age at menopause, menopausal indicators or signs, postmenopausal bleeding. N\/A
\nWell being Promotion Feminine Genital: Final gynecologic checkup, final Pap take a look at and outcomes; N\/A
\nSexual Well being: Presently in a relationship involving intercourse? Sure. Are points of intercourse passable to you and accomplice? Sure. any dyspareunia (for feminine), any adjustments in erection or ejaculation (for male) None. use of contraceptive, is contraceptive methodology passable? N\/A. Use of condoms, how incessantly? None. Conscious of any contact with accomplice who has sexually transmitted an infection (gonorrhea, herpes, chlamydia, venereal warts, HIV\/AIDS, syphilis)? None
\nMusculoskeletal System: Historical past of arthritis or gout. Within the joints: ache, stiff-ness, swelling (location, migratory nature), deformity, limitation of movement, noise with joint movement. Within the muscle groups: any ache, cramps, weak point, gait issues or issues with coordinated actions. Within the again: any ache (location and radiation to extremities), stiffness, limitation of movement, or historical past of again ache or disk illness. None
\nWell being Promotion Musculoskeletal: How a lot strolling per day? 2 miles What’s the impact of restricted vary of movement on day by day actions, corresponding to on grooming, feeding, toileting, dressing? None. Any mobility aids used? None
\nNeurologic System: Historical past of seizure dysfunction, stroke, fainting, blackouts. In motor perform: weak point, tic or tremor, paralysis, coordination issues. In sensory perform: numbness and tingling (paresthesia). In cognitive perform: reminiscence dysfunction (latest or distant, disorientation). In psychological standing: any nervousness, temper change, despair, or any historical past of psychological well being dysfunction or hallucinations. None
\nHematologic System: Bleeding tendency of pores and skin or mucous membranes, extreme bruising, lymph node swelling, publicity to poisonous brokers or radiation, blood transfusion and reactions. Endocrine System: Historical past of diabetes or diabetic signs (polyuria, polydipsia, polyphagia), historical past of thyroid illness, intolerance to warmth or chilly, change in pores and skin pigmentation or texture, extreme sweating, relationship between urge for food and weight, irregular hair distribution, nervousness, tremors, want for hormone remedy. None
\nPractical Assessment (Together with Actions of Each day Residing)
\nSelf-Esteem, Self-Idea: Schooling (final grade accomplished, different important coaching) __University____________
\nMonetary standing (earnings ample for way of life and\/or well being considerations) __________
\nWorth-belief system (spiritual practices and notion of non-public strengths) ___________
\nSelf-care behaviors _Eating a very good stability weight loss program and really active_____________________
\nExercise and Train: Each day profile, ordinary sample of a typical day __Exercise as soon as in every week by strolling 2 miles ______________________
\nImpartial or wants help with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair switch, strolling, standing, climbing stairs ___None______________________________
\nLeisure actions ____Spend time with family____________________________________
\nTrain sample (kind, quantity per day or week, methodology of warm-up session, methodology of monitoring: Strolling
\nSleep and Relaxation: Sleep patterns, daytime naps, any sleep aids used __None_________________
\nVitamin and Elimination: Document 24-hour weight loss program recall. __No weight loss program restriction _____________________________________ _____________________________________________________________________________________
\nIs that this menu sample typical of most days? ___________________________________________________
\nWho buys meals? __The Affected person purchase his food__________________________
\nWho prepares meals? ___The affected person\u2019s spouse prepares the meals and the affected person help within the kitchen______________________
\nFunds ample for meals? ___Yes_______________________________
\nWho’s current at mealtimes? __The affected person ________________________________
\nInterpersonal Relationships and Assets: Describe personal function in household __Father_______________________
\nHow getting together with household, buddies, co-workers, classmates _Patient get alongside very nicely with buddies and family_____________________
\nGet help with an issue from? ____wife __________________________________________
\nHow a lot day by day time spent alone? ____None spent most time with family_______________________ Is that this pleasurable or isolating? Pleasurable____________________________________________
\nCoping and Stress Administration: Describe stresses in life now __Combining work and household collectively ________________________________ _____________________________________________________________________________________ Change(s) in previous 12 months ______None________________________________________
\nStrategies used to alleviate stress __relaxing and movie_____________________
\nAre these strategies useful? _Yes__________________________
\nPrivate Habits:
\nEach day consumption caffeine (espresso, tea, colas) __None____________________________________
\nSmoke cigarettes? ___None________________ Quantity packs per day ___None___________
\nEach day use for what number of years ___N\/A___________ Age began __N\/A_________
\nEver tried to stop? __N\/A__________________ How did it go? ___N\/A___________________
\nDrink alcohol? _No__________________ Date of final alcohol use __N\/A_____
\nQuantity of alcohol that episode ______N\/A____________________________________________________
\nOut of final 30 days, on what number of days had alcohol? ____________________________________
\nEver advised had a ingesting downside? __No__________________________________________________ Any use of avenue medication? __None______Marijuana? _None________________________________
\nCocaine? ____None______________________________ Crack cocaine? __N\/A__________________ Amphetamines? __N\/A______________ Heroin? ____N\/A______________
\nPrescription painkillers? ___N\/A____________ Barbiturates? ___N\/A____________________________ LSD? ____N\/A_________________________________
\nEver been in therapy for medication or alcohol? __N\/A______________________________________________
\nAtmosphere and Hazards: Housing and neighborhood (kind of construction, reside alone, know neighbors) _City, Reside with household ____________________________________________________________________________________
\nSecurity of space ___Good________________________________________________________________ Sufficient warmth and utilities _____Good___________________________________________________
\nEntry to transportation ____Yes________________________________________________________
\nInvolvement in neighborhood providers ___No_________________________________________________ Hazards at office or residence ___None___________________________________________________ Use of seatbelts _______Yes_____________________________________________________________
\nJourney to or residence in different nations ___No_____________________________________________ Army service in different nations ___No_______________ Self-care behaviors _______________ Intimate Accomplice Violence: None How are issues at residence? Good Do you’re feeling secure?___Yes____________
\nEver been emotionally or bodily abused by your accomplice or somebody necessary to you: __No_-
\nEver been hit, slapped, kicked, pushed, or shoved or in any other case bodily harm by your accomplice or ex-partner? No______________________________________________________________________________ Accomplice ever drive you into having intercourse? _No__________________________________________ Are you afraid of your accomplice or ex-partner? ____No____________________________
\nOccupational Well being:
\nPlease describe your job. ___Independent Contractor___________________________
\nWork with any well being hazards (e.g., asbestos, inhalants, chemical compounds, repetitive movement)? _________________No__________________________________________________________________
\nAny gear at work designed to cut back your publicity? No
\nAny work applications designed to watch your publicity? ____No_____________________________
\nAny well being issues that you simply suppose are associated to your job? __No___________________________
\nWhat do you want or dislike about your job? ___I like the truth that is versatile for me _________________
\nNotion of Personal Well being:
\nHow do you outline well being? _My well being has been good so far_________________________
\nView of personal well being now __No main sickness which I\u2019m pleased about. Every little thing seems to be perfect______________________________________________________________
\nWhat are your considerations? __None ______________________________________________________________
\nWhat do you anticipate will occur to your well being in future? ___considering the truth that I don\u2019t have any underlying sickness, I anticipate to be wholesome in future like I’m proper now. ____________________
\nYour well being targets __continue to keep up my weight, eat extra of wholesome meals to maintain healthier____________________________________________________________________
\nYour expectations of nurses, physicians _I anticipate the nurse and physicians to responds to my considerations\/ wants when wanted and in addition proceed to deal with all of the affected person with respect and love like they’ve been doing __________________________________________________<\/p>\n
====<\/p>\n
NUR2092 WRITE-UP\u2014HISTORY OF HEALTH Classroom Assignment Week Two Date ___4\/16\/22____________ Examiner _ __________
\n1. Biographic Knowledge Title: ___ _____________________________________ Cellphone _________________ Address__ Il_________________ Birthdate ________________________________ Birthplace ______ ________ Age __37________ Gender _____Male_____ Marital Standing _ Married _____________ Occupation __Independent Contractor________ Race\/ethnic origin __ _____________________ Employer __ __________________
\n2. Supply and Reliability: From Affected person<\/p>\n
three. Cause for Searching for Care: Annual medical check-up<\/p>\n
four. Current Well being or Historical past of Current Sickness: None<\/p>\n
Previous Well being
\nDescribe basic well being __Good____________________________________________________ Childhood diseases ____None____________________________________________________________ Accidents or accidents (embrace age) ___None________________________________________________ Critical or persistent diseases (embrace age) _ None______________________________________________ Hospitalizations (what for? location?) ___None_______________________________________________ Operations (identify process, age) _____None_______________________________________________ Obstetric historical past: Gravida __N\/A__________ Time period ___N\/A_________ Preterm ___N\/A_________ (# Pregnancies) (# Time period pregnancies) (# Preterm pregnancies) Ab\/incomplete _N\/A____________________ Kids residing _____N\/A________________ (# Abortions or miscarriages) _N\/A____
\nCourse of being pregnant
\n____N\/A____________________________________________________________ ( Date supply, size of being pregnant, size of labor, child\u2019s weight and intercourse, vaginal<\/p>\n","protected":false},"excerpt":{"rendered":"
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