Nursing Assignment - Health History Assessment and Physical Assessment

Running head: NURSING ASSIGNMENT
OVERVIEW OF DIFFERENT PHYSIOLOGICAL SYSTEMS
Name of the Student
Name of the University
Author Note

1NURSING ASSIGNMENT
Health History Assessment and Physical Assessment:
A health history assessment was done for Mrs X (hypothetical name); a 65 year old patient
diagnosed with a recent episode of Menorrhagia, but otherwise is healthy. The following
information was obtained from interview with the patient:
Demographic Data: The date of birth of Mrs X is April 1st, 1952. She was born in Houston,
Texas, where she has been living with her husband for the last 30 years. They both reside in
their own house, in a ranch. She is a Christian, and since the last 30 years, she has been
helping her husband in his cattle rearing business.
Reason for admittance: Regular checkup.
Present Illness: Mrs X companied of a recent Menorrhagia, however presently she has no
health problems. PQRST assessment not applicable in present scenario.
Perception of Health: The patient had no current physical problems, and came to the hospital
for a routine checkup. She mentioned about a recent episode of Menorrhagia, however, she
was doing well now.
Past Medical History: The patient informed that she never had any past medical problems
(apart from the recent episode of menorrhagia), and is not on any medication currently.
However, the patient has a BMI of 34.75 (obese).
Family Medical History: The patient informed that her father was diagnosed of
Hypertension and Type 2 Diabetes. Apart from that, the patient informed that there was no
other history of medical problems in her family. Her husband is also healthy, and is not on
any medication.
Review of Systems:

2NURSING ASSIGNMENT
Assessment of vital signs showed the following results:
Temperature: 99.6 degrees Celsius
Pulse Rate: 70 per minutes
.Blood Pressure: 110/70
Respiration 18
Oxygen Saturation Level 99%
The patient did not complain of any pain or discomfort currently.
Developmental Considerations: Since the patient was healthy, and had no current physical
ailments, no developmental consideration was noted.
Cultural Considerations: The patient is a devout catholic, and believes that she does not need
medical assistance, as she is blessed with good health. She believes that praying regularly
kept her husband and herself free from any ailments.
Psychosocial considerations: The patient seemed to be psychologically well, and showed no
signs of emotional disturbance.
Presence or absence of collaborative resources: Since the patient had no previous history of
medical conditions, no relevant details about previous health assessment was documented for
the patient. The patient’s husband is the provider of resource.
Objective Data- Physical Exam Components:
The HEENT (or Head, Eye, Ear, Nose, Throat) is one of the primary examination
done, to check for abnormalities in these systems (HEENT exam, 2017). The head (and
cranium) houses the most important part of the central nervous system, the brain, and have