1Running head: HEALTH HISTORY

Health History

Samantha Candela

Chamberlain College of Nursing

NR 302: Health Assessment


Professor Moersch

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Health History Assessment

I choose to do a health assessment on a family friend. I will use AH has her initials.

Demographic Data

AH is 63 years old, a female, Caucasian, and lives in a house. She lives in a rural area

where she lives alone but has family close by.

Perception of Health

To her healthy means being in good health, getting regular exercise, and eating nutritious

food. Unhealthy to her means not being in good health, overweight, and eating bad foods. She

feels like she is between healthy and unhealthy. She is not in the best health, exercises once a

week, and eats good most of the time. She would like to increase her health and the amount of

exercise she gets.

Past Medical History

Her past medical history includes degenerative disc disease, high blood pressure,

hyperlipemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis.

Her past surgical history includes neck and back surgery, removal of gallbladder, removal of

cataract, and hysterectomy. The medications she takes daily include a Spiriva inhaler, allegra,

valium, Zoloft, gabapentin, Lopressor, and protonix.

Family Medical History

Both of her parents had high blood pressure, which lead to her high blood pressure. Her

mother had asthma, which increased her chance of having it. Her father had lung cancer from

smoking cigarettes. Her mother was anemic and had to have a lot of blood transfusions.

Review of Systems

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The only skin issue that she has is eczema. Her hair has some grey in it and her nails are

fine. She doesn’t have any headaches, head injury, or dizziness. She has some pain in her neck

when she turns her head to the right. She doesn’t have any lymphatic issues. She has decreased

vision and had some cataracts. She wears eyeglasses and had cataract removal surgery in June

2015. She doesn’t have any earaches or infections and her hearing is good. She has allergies to

pollen and dust but no other major sinus issue. Her mouth and throat look good, no mouth pain,

sore throat, toothaches, or lesions. She has asthma and emphysema, which causes her to have

shortness of breath. Even with her breathing problems she can still take care of herself, cook, and

clean. Her only heart related use is high blood pressure and she controls that with medication and

controls her salt intake.

Developmental Considerations

She has had asthma since she was a little girl and this has caused her some issues

growing up. She couldn’t play sports and play with friends for long because she would start

having trouble breathing. She did not have many friends growing up and had trouble with

weight; she always thought that her asthma caused this.

Cultural Considerations

Growing up she was always interested in going to church but her family wasn’t very

religious. She always wanted to study her bible and her father would always have mean

comments to say to her. This made it hard for her to go to church and be able to have a religious


Psychosocial Considerations

She lost her husband almost a year ago and has had trouble with wanting to be social. She

doesn’t like to attend social events because that was something her and her husband always used

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to do together. Her children are great about coming to visit her. At least one of them comes by

daily and they have a weekly family night.

Collaborative Resources

Her family helps her by visiting everyday and going to any doctor appointments with her.

She has a group of friends that go to church every Sunday together then go to lunch afterward.

Her neighbor and her get together a few days of the week and walk to get exercise.


This interaction helped me to practice some of the skills I learned in health assessment.

We were able to talk about her medical history well since I know a lot of the medical terms and

she also does because of how much she has had to be at hospitals. During the review of systems

she had trouble understanding some of the questions I asked but we overcame it by me

explaining each subject. I now realized I should have asked her more about any cultural issues.

This study source was downloaded by 100000792604172 from on 09-27-2022 14:53:34 GMT -05:00



American Psychological Association. (2010). Publication manual of the American Psychological

Association (6th ed.). Washington, DC: Author.

Jarvis, C., Tarlier, D., Pelt, L. V., Andrews, M. E., & Jarvis, C. (n.d.). Physical examination and

health assessment (7th ed.).

This study source was downloaded by 100000792604172 from on 09-27-2022 14:53:34 GMT -05:00 by TCPDF (

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