Nursing Assignment: Health Assessment and Client Education Report

This nursing assignment presents a comprehensive health history report of a 19-year-old female client, Miss G, detailing her physical and mental health profile. The report includes an introduction, a brief description of the client, and the purpose of gathering subjective data, which is crucial for assessing the client's past medical history, current symptoms, and health beliefs. It explains the rationale for each component of the health history, including past medical history, allergies, family history, personal strengths, health beliefs, social activities, and stress management. The assignment also highlights the client's strengths, such as her dedication to studies and work, and identifies potential health risks, including a history of depression and family history of mental health issues and other medical conditions. Furthermore, the report emphasizes the importance of health promotion and client education to empower the client to lead a normal life after her surgeries. Finally, it discusses developmental considerations and the need for emotional and psychosocial support, concluding with a summary of the client's health screening and the significance of subjective data, client education, and health promotion in improving her health outcomes. References are provided to support the information presented.

Running head: NURSING ASSIGNMENT
Nursing assignment
Name of the Student
Name of the University
Author note

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Introduction
The essay discusses the physical and mental health profile of the client Miss G for
interview and completion of a Comprehensive Health History. She is a student & part time retail
assistant lives in City Apartments, Wintec, Hanultan, New Zealand. She was born on 19 October
1997 and in a De Facto relationship. She underwent cheiloplasty, nasal repair, alveolar bone
graft and fistula repair, tip rhinoplasty, toe repair, eardrum repair (tympanoplasty) and
rhinoplasty. The essay also discusses the purpose of subjective data, the rationale for the health
history, client's strength, and health risks, the importance of client education and health
promotion and developmental considerations.
Brief description of client
The chosen client for the interview is Miss G who is 19 years old female. She is a student
& part time retail assistant and a New Zealand European with English proficiency and knows the
Spanish and Maori language. Her family members include her mother, father, oldest brother and
younger sister. She underwent cheiloplasty, nasal repair, alveolar bone graft and fistula repair, tip
rhinoplasty, toe repair, eardrum repair (tympanoplasty) and rhinoplasty. Her general health is
good; however, has a mental health history of depression and chronic mood swings when her
parents got divorced.
Purpose of gathering subjective data
Subjective data is an essential component of health assessment of a client that involves
the collection of information through effective communication (Reyes & Rosso, 2012, p. 756). In
this data, the patient provides information about the physical symptoms and how one feels about
it. This information helps to know the degree of pain that the patient is going through like

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discomfort, itching, pain or any abnormal sensations (Stumblingbear-Riddle & Romans, 2012, p.
1). In the subjective data provided by Miss G provides information about her past abdominal
pain, mental health status and allergies. The subjective data also comprises of the experiences
like vomiting, coughing or muscular spasms (Forbes & Watt, 2015, p. 175). In such kind of data,
health beliefs are also mentioned that provide information about their attitudes, beliefs and
perceptions (Coulter, Locock, Ziebland, & Calabrese, 2014, p. 348).
Collection of subjective data also encompasses feelings, sensations, desires, beliefs,
ideas, personal information, ideas and values. This is important to know about the past medical
history for the correct diagnosis, plan nursing goals and develop interventions according to the
subjective data provided by the patient (Crisp, Douglas, Rebeiro, & Waters, 2016, p. 245).
Rationale for each component of the health history
The rationale for obtaining past medical history is important as it contains pieces of
information that help to know about the current and past health history of the client (Cole &
Bird, 2013, p. 325). The diagnosis helps to provide information about the various aspects of
mental and physical health conditions like depression, retardation, hypertension or other medical
conditions (Jones, Jones, & Del Campo, 2013, p. 115). The known allergies also provide
information about the allergies to food, medications or any bee sting and plan to avoid those the
client is allergic to. Past family history, information up to three generations is important to know
about the environment, lifestyle and genes (Thornton, 2013, p. 456). It gives us a clue of the
medical conditions that are inherited in the family tree. The pattern of inheritance also provides
information about the patterns of disorders and the risk for developing that particular condition.
Personal strengths, health beliefs, social activities and stress management information is

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important as these factors also affect the quality of life and health outcomes (Hareven, 2013, p.
305).
Client’s strengths related to health and well-being
The client personal strength is that she is dedicated to her study and work. She is a
hardworking girl, high family oriented, multitasking, pursue task, and love to take challenges.
Her life values and personal beliefs are her strengths that help her to lead a happy and contended
life. She values respect a lot and are always kind to others irrespective of the person. She respect
elders, put them at first and believes that they are experienced people and one always keeps
learning from them. As she is a hardworking girl, she believes that it is the key to success and
very thankful to the Almighty. She believes that education is the foundation for a successful life
and one should never take his or her life for granted. This assessment is necessary to avoid any
kind of conflict with the client’s personal beliefs and increased participation of the patient in the
care plan and decision-making process.
The client’s risks to health and well-being
As such, Miss G has no risk to her health and well-being as she maintains a healthy
lifestyle with proper rest and weight and nutritional management. However, she had a past
mental history of chronic mood swings and depression. This took place when her parents got
divorced. This poses a risk to her health and well-being as it has a detrimental effect, as she is
family oriented and respect elders. She is bonded with her family, and parents’ separation
negatively affected her. Her birth mother has a migraine that might act as a risk factor for her
that affects her physical and mental health status. In addition, her mother also suffers from
depression, post-traumatic stress disorder migraine and hypotension. She is at risk as she might

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also develop any of these mental health disorders, as there are chances of inheritance. She had
undergone seven surgeries that have deteriorated her quality of life and well-being. Her father
suffers from high cholesterol that might also act as a risk factor, although she leads a healthy and
active lifestyle. The family history of Miss G also suggests that depression, high diabetes and
mental health problems run in the family that can be the biggest health risk factor for Miss G.
Health promotion/client education
Health promotion and client education is important for the patients to motivate and
encourage them to seek good health that acts as a desirable state by adoption of healthy practices
(Sørensen, et al., 2012, p. 80). Health promotion through the adoption of healthy lifestyles and
advertising of healthy practices help them to avoid the unhealthy lifestyles and behavioural
factors that might put one at risk. Client education is vital as it provides information on how to
maintain good health. Client education is a type of educative strategy that has a preventative
objective to help client adopt healthy behaviour and maintain a healthy lifestyle.
Education provided to the client by a healthcare professional is an important tool for the
management of care plan, provide preventative measure and promote good health for a quality
living (Schulz & Nakamoto, 2013, p. 5). Apart from health literacy, health promotion is
necessary for the client to enable him or her to increase control over the health and improve it
and exercising control over the determinants of health. In the given health, history of Miss G, the
client education and health promotion is required in terms to empower her to lead a normal life
after her past surgeries. Client education would help her to have an improved understanding of
her medical conditions, manage the multiple aspects of her health and have self-advocacy to act
independently and increase her compliance and motivation. When she would be educated about

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her medical condition, it would help her to respond well to her treatment and care plan with less
complication. Educating Miss G would also help to enhance her safety and cope with her stress
and anxiety related to her health condition.
Developmental considerations
Developmental considerations are important as every person has different capacity to
understand, comprehend and integrate the concepts of loss and separation and physical finality
(Ng, et al., 2012, p. 340). As Miss G is an adult, she can accept her physical conditions and the
separation of her parents. However, she is a very family-oriented person and respect elders, so it
was difficult for her to cope up with her parents’ divorce and separation. Due to this, she had
depression and chronic mood swings as mentioned in her mental health history. This shows that
for her developmental considerations, it is important to provide her emotional and psychosocial
support so that she can cope up with the stress and pain of her parents’ separation. Counselling
can also be provided to her as a part of the developmental consideration and promote self-
advocacy.
Conclusion
From the above discussion, it can be concluded that she underwent a health screening
consisting of STD and STI swab test as she reported abdominal bleeding. She was screened for
ectopic pregnancy and ovarian cysts. She has an allergy from bees and mosquitoes that cause
swelling in the infected areas, instant dizziness, acute burning and itchy pain at the infected area.
The purpose of subjective data is to know about the past medical history for the correct
diagnosis, plan nursing goals and develop interventions according to the subjective data provided
by the patient. The health template is helpful in increasing her control over her health and

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improves her condition. In addition, it is important for the client education and health promotion
to help her lead a normal life.
References

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Cole, S. A., & Bird, J. (2013). The Medical Interview E-Book: The Three Function Approach.
Elsevier Health Sciences.
Coulter, A., Locock, L., Ziebland, S., & Calabrese, J. (2014). Collecting data on patient
experience is not enough: they must be used to improve care. BMJ: British Medical
Journal (Online), 348.
Crisp, J., Douglas, C., Rebeiro, G., & Waters, D. (2016). Potter & Perry's Fundamentals of
Nursing-Australian Version-eBook. Australia: Elsevier Health Sciences.
Forbes, H., & Watt, E. (2015). Jarvis's Physical Examination and Health Assessment. Elsevier
Health Sciences.
Hareven, T. K. (2013). Transitions: The family and the life course in historical perspective.
Elsevier.
Jones, K. L., Jones, M. C., & Del Campo, M. (2013). Smith's Recognizable Patterns of Human
Malformation E-Book. Elsevier Health Sciences.
Ng, J. Y., Ntoumanis, N., Thøgersen-Ntoumani, C., Deci, E. L., Ryan, R. M., Duda, J. L., &
Williams, G. C. (2012). Self-determination theory applied to health contexts: A meta-
analysis. Perspectives on Psychological Science, 325-340.
Reyes, A., & Rosso, P. (2012). Making objective decisions from subjective data: Detecting irony
in customer reviews. Decision Support Systems, 754-760.
Schulz, P. J., & Nakamoto, K. (2013). Health literacy and patient empowerment in health
communication: the importance of separating conjoined twins. . Patient education and
counseling,, 4-11.

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Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., & Brand, H.
(2012). Health literacy and public health: a systematic review and integration of
definitions and models. BMC public health, 80.
Stumblingbear-Riddle, G., & Romans, J. S. (2012). Resilience among urban American Indian
adolescents: Exploration into the role of culture, self-esteem, subjective well-being, and
social support. . American Indian and Alaska native mental health research (Online), 1.
Thornton, A. (2013). Reading history sideways: The fallacy and enduring impact of the
developmental paradigm on family life. University of Chicago Press.