Health History RUA
Chamberlain University College of Nursing
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NR-302: Health Assessment I
Professor Johnson
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February 12, 2021
Health History Assessment
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I chose to do my health assessment on one of my classmate’s from my Health Assessment
I lecture course. I will use SP as her initials throughout the document.
Demographics
SP is a single, 23-year-old, Asian female who lives at home with her parents in the
suburbs. She is currently attending Chamberlain University as a full time nursing student. She is
not employed at the moment and does not have an income.
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Perception of Health
Her definition of being health means getting a moderate amount of exercise each week.
This includes exercise, consuming nutritious foods, and having no medical issues. SP is in good
standing healthwise. She works out three to four times a week for approximately sixty minutes.
She also eats nutritious foods most of the time. She wants to continue to maintain a healthy and
balanced lifestyle.
Past Medical History
SP has a past medical history of suffering from migraines starting from the age of 18
years old. She did not report any illnesses from the measles, mumps, rubella, chickenpox,
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rheumatic fever, and polio. All of her immunizations are up to date as of January 2021. Her past
surgeries include wisdom teeth removal which was performed in May of 2012. She had two past
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hopsitalizations. Unfortunately, she was in a very bad car accident in June of 2001 and fractured
her humeerus. Then, in March 2020, she got pneumonia and was hospitalized again. The client
takes 25 mg of Sumatriptan as needed for her migraine headaches. The patient also takes
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norgestimate and ethinyl estradiol birth control tablets. The patient does not have any known
allergies to any food, medications, betadine, iodine, shellfish, latex, or tape.
Family Medical History
Her mother is a 51-year-old Asian female who has a history of hypertension. Both of her
maternal grandparents are still alive. Her maternal grandmother is a 72-year-old Asian female
with a history of hypertension, hyperlipidemia, and diabetes. Her maternal grandfather is a 74-
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year-old Asian male with a history of hypertension. The patient does not know her father and
paternal grandparents.
Review of Systems
SP does not have a history of skin disease. The patient’s skin color is appropriate in
relation to her ethnicity. She does not have any complaints of dryness, moisture, or bruising. SP
reported the development of migraines in her late teenage years although she has not had any
previous head injuries. She does not have any difficulty with her vision and has never
experienced diplopia (Jarvis & Eckhardt, 2019). Her hearing is normal. The patient has no
complaints of allergies, nasal obstructions, or any changes in smell. Her neck is normal. Her lips
are normal in color. She has no pain in the mouth including sore throats, toothaches, or any
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bruising. The patient is still able to complete normal daily activites even with her complaints of
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migraines.
Developmental Considerations
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SP developed migraine headaches in her late teens/early college years. She believes that
these migraines caused her to have a difficult time staying focused in college. When she could no
longer bear the pain, she would have to take a nap to reduce it.
Cultural Considerations
Growing up in an Asian household, her mother was very strict. She did not get to take
part in any sports because her mom wanted her to be fully focused on school.
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Psychosocial Considerations
She does not know her father and paternal grandparents. She grew up without a father
figure in her life. She does not like to bring it up often, but she wonders why he did not want to
be apart of her life. However, she does have a very supportive family, especially her mom and
maternal grandparents. They have a very strong bond with one another.
Collaborative Resources
The patient tends to be very busy and occupied with school since she is a full time
nursing student, but she does make time for her friends and family as well. The patient is family
oriented and enjoys spending quality time with her mom and maternal grandparents when she
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has any free time. She occasionally meets up with her friends for lunch dates as well. It is very
important to form strong relationships with friends and family in order to improve a person’s
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quality of life (Sharp et. al., 2017).
Reflection
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Having to complete this health assessment questionnaire was a great way for me to
exercise my skills learned in health assessment I. Due to COVID-19, this interaction took place
on WebEx during our health assessment I lab time. We began the assessment at one o clock in the
afternoon. I was able to obtain consent from my classmate in order to begin the interview
process. A various amount of open ended questions were asked in order to have an effective
relationship between the patient and the nurse. I was able to learn about her medical history in
great detail. Because she provided such detailed answers, I was able to relate to and understand
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what she was going through. This interview taught me the importance of using different types of
questions according to the patient and the answers they are giving. I realized that the questions
being used has a huge effect on how the patient responds. We were both able to understand each
other during the interview process. However, since the interview took place over a video call, I
feel like neither of us gained the full patient to nurse relationship. It is hard to make the patient
feel comfortable when you do not have that one on one interaction face to face. This was a great
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learning experience and will help me improve my skills as a nurse in the making.
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References
Jarvis, J. C., & Eckhardt, A. E. (2019). Physical Examination and Health Assessment (8th ed.).
Saunders.
Sharp, P. B., Heller, W., & Telzer, E. H. (2017). Selective neural sensitivity to familial threat in
adolescents with weak family bonds. Social Neuroscience, 14(1), 80–89.
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https://doi.org/10.1080/17470919.2017.1397545
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