NR302 Health Assessment I: Detailed Health History & Reflection

This assignment presents a health history assessment of a 67-year-old female patient, M D, conducted as part of the NR302 Health Assessment I course. The assessment covers biographic data, perception of health, cultural and spiritual background, past medical history including childhood illnesses and surgical procedures, family medical history focusing on parental health conditions, and a review of systems indicating general health. The assessment also includes developmental considerations, a physical assessment noting the patient's healthy state, learning priorities emphasizing a healthy lifestyle, psychosocial considerations suggesting interaction with grandchildren, and collaborative resources recommending family support and regular physician visits. The reflection section discusses the positive interview experience, the importance of a friendly approach, challenges encountered such as time limitations and emotional responses, and future improvements in the assessment approach. The conclusion highlights the value of health assessments in meeting patient health requirements and the importance of spiritual care.

RUNNING HEAD: THE HEALTH HISTORY 1
The Health History
Name:
Institution:
Tutor:
Date:

THE HEALTH HISTORY 2
Health History assessment
INTRODUCTION
A health history assessment tool is a protocol that seeks to know specific requirements of
a patient and how they can be handled by the nurses (Ross et al., 2018). It can also be defined as
the evaluation of the health condition by carrying out a physical exam after getting a health
history (McCrae, 2015). Below is Health History assessment of a patient I interviewed.
Biographic data
M D is a 67 year old married white lady. At the moment, she has been unemployed for
close to four months. Her latest job was as a private home health assistant to a friend’s elderly
parents who unfortunately passed on. She worked at that place for seven months. M D was born
in Atalanta in a family of Mexican decent. However, she currently lives within the suburbs of
Atalanta and her primary language is English.
Perception of health
Generally D believes that she is healthy since she has never suffered from any chronic or
serious illness from childhood. Besides, she conducts regular visits to her private physician and
therefore there is no cause of alarm concerning her health.
Culture and spirituality
M D was raised as a Roman Catholic where politeness, table manners, praying before
meals, respect to the elderly, finishing her chores before engaging in recreation activities, sharing
and attending church service on every Sunday was necessary. She was also raised in a family

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where the Dad was the leader of the household though he made decisions on a mutual basis with
her mother. Besides, her parents did share different house chores as well.
Past medical history
M D has never suffered from any chronic infections at the moment and neither did she
have any serious infections while she was still a child. The only notable case however, was
chickenpox that she suffered from when she was about 4 years as well as shingles 19 years
ago.MD was as well hospitalized twice during childbirth and the obstetric results indicate
Gravida 3/term 3/preterm 0/Abortion 0/living. Out of the two childbirths, it was very unfortunate
that all of them were uncomplicated vaginal deliveries. Her surgical history is tubal ligation
when she was 20 and surgical expulsion of cysts in her right breast. With allergies, she has no
known allergy but her current over the counter drugs are 400-600 mg of ibuprofen that act as
painkillers.
Family medical History
M D did indicate that her father was a serial smoker and he was suffering from chronic
Obstructive Pulmonary up to his death. Her mother on the other hand was suffering from
hypertension up to her time of her death. Her two brothers and one sister are healthy and they
don’t have any significant health condition.
Review of systems.
M D did indicate that she is generally healthy with neither cardiac, urinary, respiratory
nor any gastrointestinal deformities. She also doesn’t have any history of skin diseases. There is
no current loss of hair. Her pupils react on light. She has no history of either glaucoma or
cataracts. Her head is norm cephalic and the ears are normal. She has no history of any chronic

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infections. Her nose as well as sinuses history has it that she experiences clear nasal discharge
though she did state that she could experience nose bleeding while she was a child. Her mouth
and throat are devoid of any lesions and the gums do not bleed. She does not experience any pain
in her neck.
Developmental considerations.
M D is already an adult and actually there is no need for developmental considerations.
She however acknowledges the positive impact on development of self-esteem by her parents
when she was still a child.
Physical assessment
From the assessment, it was very clear that M D is healthy and therefore there was no
need for any physical assessment to be carried out on her.
Learning priorities
Since M D is at 67 years old, I would recommend a healthy lifestyle since her immune
system is generally weak. This could include regular exercise, good diet and avoid alcohol and
substance abuse as well as enough rest.
Psychosocial considerations
M D should consider having good time with her grandchildren so that they can keep her
lively throughout. This is because at that age, she might be at risk of hypertension.
Collaborative resources.
M D should stay close to her family members and continue her regular visits to her
physician so as to ensure that her health is in control.

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REFLECTION
The whole interview and conversation process was really pleasant. The responded was
actually relaxed and very comfortable with the whole process. I used a very friendly approach to
M D and the interview ran for an hour within the consultation room free from any distractions.
The assessment took place during the early morning hours from 8 to 9AM. As healthcare
providers, provision of intense, time consuming interventions is necessary for spiritual care. The
spiritual assessment tool is necessary as it can guide on the spiritual supportive care. Like in this
case, what went well was the lively nature of M D and I also discovered that prayer, devotional
readings, the Catholic Church are important coping supports.
How interaction did compare with what I have learned.
I learnt in class that for an interview to be successful, the healthcare provider approach is
crucial. And actually the interview turned out successful since I approached the client in a very
friendly manner and this made her open up on several issues I asked about.
Barriers or challenges to communication
The greatest challenge was limited time in the healthcare setting since the patients are
very many. I was therefore cutting short some of the responses by the respondent. In future, I
would recommend specific days for assessments other than clinical so that all the patients get
enough time for assessment.
Unanticipated challenges
The unanticipated challenge I came across was how the responded broke down in tears
when I asked her about her parents. It was unfortunate that all her parents died and from the look

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of things, she really loved them and that is why she broke down with those memories. I never
expected this since she is old enough and she must have gone over it.
Information I wished to obtain.
The information I wished to get was how the stand of the Roman Catholic Church on
matters to do with smoking since MD talked up the idea of her father being a serial
smoker.However,I never got this information since the respondent got so emotional.
How I will alter my approach next time.
I will utilize a very informal approach next time so as the respondent can feel very
comfortable and relaxed. I can achieve this by not necessarily meeting the client at the
consultation room rather at a cafeteria and have the interview while having some coffee.
CONCLUSION
Assessment offers healthcare workers information that can be used to meet the health
requirements of patients in a better way. The assessment tool can assist a nurse go past a difficult
topic like religion and it also provides the nurse with an opportunity to know resources that can
assist to quicken the comfort and healing of the patient. All nurses should therefore adopt the
assessment tool at their work place.

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References
McCrae, N. (2015). Spiritual Care in Practice Fitchett George Nolan Steve Spiritual Care in
Practice320pp £18.99 Jessica Kingsley Publishers 9781849059763 1849059764.
Nursing Management, 22(4), 16-16. doi:10.7748/nm.22.4.16.s19
Ross, L., McSherry, W., Giske, T., Van Leeuwen, R., Schep-Akkerman, A., Koslander, T.,
… Jarvis, P. (2018). Nursing and midwifery students' perceptions of spirituality,
spiritual care, and spiritual care competency: A prospective, longitudinal,
correlational European study. Nurse Education Today, 67, 64-71.
doi:10.1016/j.nedt.2018.05.002