Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that …show more content…
Review of Systems
General Health: Reports usual health “Good”. No recent weakness, fever, fatigue or malaise, weight change, present weight 190 Lbs, overweight. Patient reports acid gastric, mild pain and gasses at night. Not on a diet. Not physical activity, sedentary life.
Skin, Hair, and Nails: No history of skin disease. Patient reports family history of allergies to penicillin, especially when skin comes in contact with dust. No other allergies to drugs, plants, or animals were reported. No change in skin color, pigmentation, nevi, or mole. No pruritus, rash, itching, lesions. No bruises present. Denies any changes in medication or its dosages. Patient is allergic to penicillin react rash. Hair, no loss (alopecia) or change in texture. No change in nails, their shape, color, brittleness. Patient denies chewing, biting nails. Patient denies environmental and occupational hazards, such as dyes, toxic chemicals, radiation. Patient reports caring for her skin, hair, and nails by maintaining good hygiene, applying non-sun blocks creams and lotions to retain moister in skin. Patient clips her own cuticles on nails. Denies previous experience with dermatitis or herpes.
Head, Face, and Neck, Including Regional Lymphatics: patient reports having severe, unilateral, throbbing, sometimes sharp, migraines episodes, occurring once a month, each lasting more than 3 hours.