NURS1004 Part 1: Documentation of Health Assessment Assignment

This assignment presents a detailed health history assessment of a 24-year-old female. The assessment covers biographical data, including the patient's background, occupation, and marital status. It delves into the patient's reason for seeking care, present and past health conditions, including childhood illnesses, hospitalizations, and allergies. The health history also includes a review of symptoms, family history, lifestyle management, and environmental hazards. The assessment further explores the patient's activity and exercise patterns, nutrition and metabolism, and renal, bladder, and bowel function. Mental status, neurological and sensory functions, and intimate partner violence are also assessed. The patient's health goals are identified as asthma management and increased water intake.

Date .......................................................................................
Interview conducted by ......................................................
Designation ..........................................................................
1. Biographical data
Name Trudy Green...................................................................................................................................................................................
Address 1208 Happy Valley.....................................................................................................................................................................
Date of birth 12th October 1989 Birthplace Ashtyn......
Age 24 Gender female Marital status single.............................................................................................................
Occupation teacher...................................................................................................................................................................................
Employer not mentioned...........................................................................................................................................................................
Nationality Australia Interpreter required? no................................................
Medicare number (Not required for the assignment) not discussed........................................................................................................
Private Heath Fund Details (Not required for the assignment) not discussed........................................................................................
Advanced care directive? Details: no.............................................................................................................................
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2. History obtained from patient herself.....................................................................................................................................................
3. Reason/s for seeking care health check-up...........................................................................................................................................
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4. Present health or history of present illness mild colds sometimes.....................................................................................................
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5. Past health
General health .......................................................................................................................................................................................
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Childhood illnesses asthma and size eyes...............................................................................................................................................
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Accidents or injuries .................................................................................................................................................................................
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Serious or chronic illnesses chronic sinusitis...........................................................................................................................................
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Hospitalisations sinus on teeth.................................................................................................................................................................
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Operations sinus on teeth.........................................................................................................................................................................
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Obstetric history no...................................................................................................................................................................................
Gravida ...................................... Term ...................................... Preterm ............................................
(# Pregnancies) (# Term pregnancies) (# Preterm pregnancies)
Term / Incomplete ..................................... Children Living .............................................................................................................
Source: Jarvis, C & Denmead, E (Australian adapting author) 2012, chapter 7 ‘The health history’, in Student laboratory manual for physical
examination and health assessment, Australian and New Zealand edition, Saunders Elsevier, Sydney, pp. 65–73.
NURS1004 Part 1 Documentation for Health assessment

(# Terminations / Miscarriages)
Course of pregnancy no...........................................................................................................................................................................
..................................................................................................................................................................................................................
(Date delivery, length of pregnancy, length of labour, baby’s weight and sex, vaginal delivery / caesarean section, complications, baby’s condition)
Immunisations
Tetanus Current Select ........................................................................................................................
Influenza Current Select flu shot coming up............................................................................................
Pneumococcus Current Select ........................................................................................................................
Other ......................................................................................................................................................................................
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Last GP visit date five or six weeks ago...................................................................................................................................................
Health Screening
Dentist five or six weeks ago Vision .......................regular check up done two weeks ago to check updates................
Hearing two years ago ECG done when young.......
CXR ......................................................................... Other .......................................................................................
Allergies: Allergens and reaction – allergy bracelet applied Select ...............................................................................................
Drugs / medications ...............................................................................................................................................................
Food preservatives 220............................................................................................................................................................
Latex / other cats, grasses, ponds...........................................................................................................................................
Comments .............................................................................................................................................................................
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Infection control
Transmission-based precautions cleaning before eating and during toileting to be hygienic.................................................
Notifiable disease ..................................................................................................................................................................
6. Family history
Heart disease paternal grandparents.......................................................................................................................................................
High blood pressure mother.....................................................................................................................................................................
Stroke both side of family.........................................................................................................................................................................
Diabetes both side type 2.........................................................................................................................................................................
Blood disorders no....................................................................................................................................................................................
Breast cancer father side, aunty died at her 40s......................................................................................................................................
Cancer (other) no......................................................................................................................................................................................
Sickle cell no.............................................................................................................................................................................................
Arthritis both side......................................................................................................................................................................................
Allergies ....................................................................................................................................................................................................
Asthma mom has asthma.........................................................................................................................................................................
Obesity no.................................................................................................................................................................................................
Alcoholism no...........................................................................................................................................................................................
Mental illness no.......................................................................................................................................................................................
Seizure disorder no...................................................................................................................................................................................
Kidney disease no.....................................................................................................................................................................................
Tuberculosis no........................................................................................................................................................................................
Other no....................................................................................................................................................................................................
Review of symptoms, function and risks
Include both past health problems that have been resolved and current problems, including date of onset.
7. General overall health and wellbeing
Perception of health moderately fit...........................................................................................................................................................
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Interpersonal relationships / resources lives with partner........................................................................................................................
Education (last level achieved) masters...................................................................................................................................
Current employment teacher....................................................................................................................................................
Family role? .............................................................................................................................................................................
Support systems? no................................................................................................................................................................
Values and beliefs / spiritual resources catholic and celebrates Easter and Christmas..........................................................................
Cultural background ...............................................................................................................................................................
Cultural health practices ........................................................................................................................................................
Religious / spiritual beliefs .....................................................................................................................................................
Coping and stress management ............................................................................................................................................................
Stressors in life? Stress, ulcers................................................................................................................................................
Methods to relieve stress try to avoid acidic foods, shops chocolates....................................................................................
Self-concept ...........................................................................................................................................................................................
Personal strengths? Confident and happy person...................................................................................................................
Life values and belief everyone should have the scope to research potential in education....................................................
Sleep / rest 10.30 to 11.00.......................................................................................................................................................................
Sleep pattern? Playing solitaries, browsing net.......................................................................................................................
Aids used? .............................................................................................................................................................................
8. Health and lifestyles management
Current medications: (prescribed and OTC). Note name, purpose, dose and daily schedule.
Ask specially about vitamins, oral contraceptives, aspirin, sedatives and antacids.
Azatec, histamine, asthma relievers, penicillin...........................................................................................................................................
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Tobacco, alcohol and recreational / street drugs
Smoke cigarettes? no Number of packs per day ....no......................................................................................................................
Daily use for how many years ...................... Age started ..............................................................................................
Ever tried to quit? ......................................... Succeed? .................................................................................................
Comments ..............................................................................................................................................................................
Drink alcohol? occasionally Date last alcohol use two weeks ago......................................................................................................
Amount of alcohol that episode apple cider..............................................................................................................................
Out of the last 30 days, how many days had alcohol? twice...................................................................................................
Ever had a drinking problem? no.............................................................................................................................................
Comments ..............................................................................................................................................................................
Any use of recreational drugs? (reinforce confidentiality of information disclosed)no
Which ones ...................................................................
Marijuana? ..................................................................... Cocaine? ....................................................................................
Crack cocaine? .............................................................. Amphetamines? ........................................................................
Barbiturates? ................................................................ LSD? ...........................................................................................
Heroin? ........................................................................ Other? .......................................................................................
Ever had treatment for drugs or alcohol? ................................................................................................................................
Other comments? ..................................................................................................................................................................................
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Environmental hazards ..........................................................................................................................................................................
Live alone? With family? partner..............................................................................................................................................
Neighbourhood? Not friendly....................................................................................................................................................
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Transportation? Drive herself...................................................................................................................................................
Occupational health ...............................................................................................................................................................................
Worked with health hazard? ...................................................................................................................................................
Health problems related to work? ..........................................................................................................................................
9. Assessing activity and exercise
Daily activities and effect of symptoms? normal......................................................................................................................................
Usual pattern of a typical day ................................................................................................................................................................
Ability to perform ADLs? ........................................................................................................................................................................
Independent or needs assistance with ADLs—select the appropriate level:
Feeding Independent/Assist Bathing Independent/Assist Hygiene Independent/Assist
Dressing Independent/Assist Toileting Independent/Assist Bed-to-chair transfer Independent/Assist
Walking Independent/Assist Standing Independent/Assist Climbing stairs Independent/Assist
Use of wheelchair, prosthesis, mobility aid? no.......................................................................................................................................
Leisure activities? Sit on couch watch tv, dancing on weekends.............................................................................................................
Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring the body’s response to exercise)
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Any other self-care behaviours: .............................................................................................................................................................
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Cardiovascular function:
Praecordial or retrosternal pain Palpitation Cyanosis
Dyspnoea on exertion (specify amount of exertion, e.g. walking one flight of stairs, walking from chair to bath or just talking)
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Orthopnoea Paroxysmal nocturnal dyspnoea Nocturia
Oedema History of heart murmer Hypertension
Coronary artery disease Anaemia Bleeding tendency
Excessive bruising Lymph node swelling
Exposure to toxic agents or radiation Blood transfusion and reactions Coldness, numbness and tingling
Swelling of legs (time of day, activity) ............................................................................................................................................
Discolouration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles)
no................................................................................................................................................................................................................
Varicose veins or complications Intermittent claudication Thrombophlebitis Ulcers
Comments ..............................................................................................................................................................................................
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Respiratory function:
Nasal discharge and its characteristics yes yellowy brown, every six weeks..................................................................................
Unusually frequent or severe colds Sinus pain yes Nasal obstruction
Nosebleeds Allergies or hay fever yes in spring, cats
Change in sense of smell
History of lung diseases (asthma, emphysema, bronchitis, pneumonia, tuberculosis) throbbing pain dull ache
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Chest pain with breathing Wheezing or noisy breathing yes when asthma
Shortness of breath
How much activity produces shortness of breath ...................................................................................................................................
Cough Sputum end of cold (colour, amount) browny yellow....................................
Haemoptysis Toxin or pollution exposure
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Comments ..............................................................................................................................................................................................
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Musculoskeletal function:
History of arthritis or gout .............................................................................................................................................................
In the joints: pain, stiffness, swelling (location, migratory nature) ...............................................................................................
Deformity Limitation of motion Noise with joint motion
In the muscles: any pain, cramps, weakness, gait problems or problems with coordinated activities? ..........................................
Swelly feet and pain resides.......................................................................................................................................................................
Back pain? (location and radiation to extremities) ......................................................................................................................
Stiffness Limitation of motion History of back pain
History of disc disease
Comments bulgy feet sometimes.............................................................................................................................................................
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10. Assessing nutrition and metabolism (including skin, hair and nails)
Skin: (eczema, psoriasis, hives) arms and part of skin, puts moisturiser................................................................................................
Sun exposure? .......................................................................................................................................................................................
Hair: (loss of hair, change in texture, distribution) shed haor all the time................................................................................................
Nails: (shape and colour) grow quickly
Mouth, teeth and throat: brush twice........................................................................................................................................................
Dental routine .........................................................................................................................................................................................
Weight: 55 or 60kg Recent weight loss or gain? ..........................................................................................................................
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Food and fluids in the last 24 hrs turkey patty and sals in dinner, London subway food and diet coke, lunch- pesto feta and sun
dried tomato, chocolate cup, pumpkin with coke, chicken tomato cheese sandwich................................................................................
Current diet / eating habits? three to more meals....................................................................................................................................
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Daily intake caffeine (coffee, tea, colas) seldom......................................................................................................................................
Heartburn? Very rarely.............................................................................................................................................................................
Nausea or vomiting ................................................................................................................................................................................
Liver or gallbladder disease? ..................................................................................................................................................................
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Abdominal pain? ....................................................................................................................................................................................
Endocrine dysfunction? .........................................................................................................................................................................
Diabetes? ...............................................................................................................................................................................................
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Any other comments? ............................................................................................................................................................................
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11. Assessing renal, bladder and bowel function
Voiding pattern .......................................................................................................................................................................................
Frequency, urgency? Regularly frequently...............................................................................................................................................
Nocturia ..................................................................................................................................................................................................
Incontinence? no......................................................................................................................................................................................
Fluid intake for 24 hrs a litre or so............................................................................................................................................................
Mobility to toilet? No incontinence............................................................................................................................................................
History of urinary system disease: ..........................................................................................................................................................
Kidney disease Kidney stones Urinary tract infections
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Prostate Pain in flank Pain in groin
Pain in suprapubic region Pain in low back
Comments: .............................................................................................................................................................................................
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Bowel function three days interval............................................................................................................................................................
Pattern of elimination, frequency ...........................................................................................................................................................
Stool characteristics? .............................................................................................................................................................................
Other comments? ..................................................................................................................................................................................
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12. Assessing mental status, neurological and sensory function
Mental status:
Nervousness Mood change sometimes
Depression
Comments: was knocked by broom of the boat in high school. No effects.............................................................................................
Mental health dysfunction or hallucinations? ..........................................................................................................................................
Neurological function:
Any head injury Dizziness (syncope) or vertigo sometimes due lack of fluid and water
Fainting
Blackouts Motor function Tic or tremor
Paralysis Coordination problems
Comments: ..............................................................................................................................................................................................
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In sensory function:
Numbness and tingling (paraesthesia)
Seizures? no.............................................................................................................................................................................
Stroke? no................................................................................................................................................................................
Weaknesses? no......................................................................................................................................................................
Memory disorders? no..............................................................................................................................................................
Headaches? No, only when i am stressed, tired, hungry........................................................................................................
Eyes:
Decreased acuity no Blurring yes when stressed Blind
spots no
Eye pain sometimes Diplopia (double vision)no
Redness or swelling when tired
Watering or discharge rarely Glaucoma Cataractsyes
Visual problems? Glasses? Yes, astigmatism ........................................................................................................................
Ears: no issues
Earaches Infections
Discharge and its characteristics
Tinnitus or vertigo Hearing loss Hearing aid use
How does loss affect daily life? no...........................................................................................................................................................
Any exposure to environmental noise? no...............................................................................................................................................
Method of cleaning ears? no.....................................................................................................................................................................
Hearing difficulties? no.............................................................................................................................................................
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Sensory function (feet, hands) no............................................................................................................................................
Other comments? no................................................................................................................................................................................
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13. Intimate partner violence: (Ask if required or if IPV suspected)no issues
How are things at home? fine....................................................................................................................................................................
Do you feel safe? yes...............................................................................................................................................................................
Have you ever been emotionally or physically abused by your partner or someone important to you? no............................................
Have you ever been hit, slapped, kicked, pushed or shoved or otherwise physically hurt by your partner or ex-partner? no................
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Has your partner ever forced you to have sex? no..................................................................................................................................
Are you afraid of your partner or ex-partner? no......................................................................................................................................
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Any comments? No comments.................................................................................................................................................................
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Summary statement a 24 year old woman living with partner, employed, living in own bought house, needs to manage
asthma and have water ..........................................................................................................................................................................
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Patient’s health goals asthma management
Water intake increase.................................................................................................................................................................................
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