Comprehensive Health Assessment Essay

Words: 5986
Pages: 24
Open Document
COMPREHENSIVE WRITTEN ASSESSMENT

Complete Nursing Health History
Biographical Data
Name: B.R.
Address: xxxxxxx
Phone: xxxxx
Gender: Female
Provider of History: Client
Birth Date: February 2, 1973
Place of Birth: Portland, Oregon
Race: Caucasian
Educational Level: Associate’s Degree in Nursing and currently pursuing Bachelor’s of Science in Nursing
Occupation: Registered Nurse
Significant Other: Fiancé “Mark”
Support Person(s): Mother & Brother
Reason for Seeking Healthcare Client is currently seeking healthcare for her yearly routine physical. Client’s last check-up with her primary physician was one year ago, at which time, no abnormal findings were noted. Client is confident with her health at this time …show more content…
Client does not have a specific religious affiliation. Client states that she believes in the “Golden Rule” –that you should treat others how you want to be treated.
Education & Work Client graduated from nursing school last year and has been pursuing her Bachelor’s degree since. Client plans on continuing on with her Master’s Degree. Client reports that she loves her new career choice and is excited about her future in nursing.
Stress Level/Coping Going back to school, while maintaining a full-time job, and planning a wedding is a bit of a challenge for this busy student. She at times has conflictions with her fiancé’s ex, but does try to separate herself from the situation, and uses deep-breathing as a form of stress-reduction. Client does not feel stressed at this time.

Environmental Hazards Client lives in a small development in Salisbury with the majority of her neighbors being retirees. Her neighborhood is quiet and she is comfortable living in this community. There are no known environmental risks for her.
Physical Assessment

Head/Face/Neck
Subjective
Client denies any neck pain. Client denies any complaints of headaches. No photophobia. Client denies any facial pain. Client denies any problems or difficulty with moving head or neck. Client denies any lumps or lesions on the head or neck. Client denies any dizziness, lightheadedness,
Show More

Related Documents: Comprehensive Health Assessment Essay

Comprehensive Health Assessment Paper

Comprehensive Health Assessment A comprehensive health assessment involves the collection of data that concerns the patient. Comprehensive patient assessment is vital because it plays a crucial role in coming up with data to develop the best care for the patient. Prioritizing comprehensive health evaluations is essential for health organizations. The evaluation results help nurses choose the best course of action. Steps in the nursing assessment process include taking a patient's history, making…

Words 1137 - Pages 5

Essay on Executive Health Brochure 1

good health is the cornerstone of a... fulfilling life 9500 Euclid Avenue, Cleveland, OH 44195 canyonranch.com The Cleveland Clinic Foundation is an independent, not-for-profit, multispecialty academic medical center. It is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 available beds, an education division and a research institute. Canyon Ranch has been offering healthy, active vacations for over 25 years. The life enhancement…

Words 2387 - Pages 10

EGT1 Task 3

What does it mean to document accurately and appropriately? The quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry (Dehghan, Dehghan, Sheikhrabori, Sadeghi, & Jalalian, 2013). Keeping documentation accurately and appropriately, while dedicating our time to patient care is tantamount to delivering safe care; it is part of our duty to work and develop a safe environment. The quality of our documentation reflects the quality of our…

Words 1232 - Pages 5

Risk Assessment Tool In Nursing

Risk assessment is paramount in deciding on the most appropriate level of risk management and the right kind of intervention required by the service user this is according to the Department of health in 2007. Assessing risk is a systematic and collaborative process of identifying and explore factor which are associated with a high probability of a specific risk behaviour occurring, in addition involves the collection of information from different sources to ascertain the level and likelihood of…

Words 960 - Pages 4

Roper-Tierney Model Paper

understanding, and a compassionate presence. In this case, Rosie is an 80 year old woman, who is present for a regular check-up to ensure she is in good health. Working as a practice nurse in a rural Queensland GP clinic, Cameron, will be employing the Roper-Logan-Tierney (RLT) Model and the Clinical Reasoning Cycle (CRC) to provide comprehensive and the best person-centred care for her (NMBA, 2016).…

Words 1220 - Pages 5

Nsqhs Standards

National Safety and Quality Health Service (NSQHS) aims to deliver safe and high quality care to protect the public and improve health care. They are 8 standards, Comprehensive Standard aims to ensure every patient established comprehensive care and meet every individual needs. This can include the impact of the patient health issues on their wellbeing and life (NSQHS, 2017). It also means delivering the right care that is planned and coordinated within their mental and physical needs. Mrs smith…

Words 141 - Pages 1

Metabolic Syndrome

Leiva Martinez University of Phoenix Master of Science in Nursing/Psychiatric Mental Health Nurse Practitioner Advanced Pathophysiology NRP/511 Vincent Smith May 21st, 2024. Introduction Metabolic syndrome is a complex and interrelated cluster of metabolic abnormalities that significantly increases the risk of cardiovascular disease and type 2 diabetes. This case study presents the assessment and diagnosis of a patient with metabolic syndrome using the POLDCARTS method, along with…

Words 784 - Pages 4

Treva Throneberry Ap Psychology Essay

psychophysiological measurement as the major techniques used. Anxiety-related disorders are commonly measured through a variety of techniques, each offering unique insights into the individual's experiences. Interviews, conducted by trained mental health professionals, involve structured or semi-structured conversations to assess symptoms, triggers, and the impact of anxiety on daily life. Self-report questionnaires, such as the Beck Anxiety Inventory or the Generalized Anxiety Disorder 7-item scale…

Words 2795 - Pages 12

Family Development Theory: Family Assessment

above poverty level; we do have health insurance, and able to buy food and clothing. According to the Family Development Theory, my family is in two stages. The stage we are in is families with school children (child is aged 6-13 years) and families with teenagers (children 13 to 20 years) (Office of Family Science Education, 2016). I believe we are in 2 stages because of the wide spread we have between our children. At this time my family does not have any health issue. My husband did have replacement…

Words 697 - Pages 3

EMR Effects On Health Care

EMRs in to the health care system? Technology is changing our world at top speed and it is becoming increasingly evident in many health care settings (Huston, 2013). There are numerous technologies that will ultimately change the practice of nursing in the coming decades (Huston, 2013), with one of those changes being the widespread use of the electronic medical record (EMR). An EMR is “an electronic application through which individuals can access, manage, and share their health information and…

Words 909 - Pages 4