Comprehensive Health Assessment Essay

Words: 5986
Pages: 24


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
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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

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,