NR 302 HEALTH ASSESSMENT Running Head: THE HEALTH HISTORY
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NURSING
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NURSING
NR 302 HEALTH ASSESSMENT Running Head: THE HEALTH HISTORY
The Health History Chamberlain College of Nursing NR-302: Health Assessment I September 2018
J. O. is a 27-year-old Latino male of Mexican descent, born on November 23rd, 1990, in Texas. Primary l...
nr 302 health assessment running head the health history
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NR 302 HEALTH ASSESSMENT Running Head: THE HEALTH HISTORY
The Health History
Chamberlain College of Nursing
NR-302: Health Assessment I
September 2018
J. O. is a 27-year-old Latino male of Mexican descent, born on November 23rd, 1990, in
Texas. Primary language is English, but he is fluent in Spanish, and has an elementary
proficiency in Japanese, German, and Russian. He graduated with an associate’s degree in
, 2
THE HEALTH HISTORY
Liberal Arts from a community college and also obtained a real estate license. Works part time as
a unite clerk at a large private hospital in New York City and also works as a real estate agent.
Patient is alert and oriented, sitting upright, with no signs of distress, nervousness, or slurred
speech. Patient is well groomed and dressed appropriately for the weather and situation.
Perception of Health
Patient works in a health care setting and has a good perception of health. Patient states
that he is healthy in general but would like to lose some weight. He exercises twice a week but
would like to increase his physical activity to four times per week. Patient is also concerned with
contact dermatitis and “psoriasis at the hairline.” Patient confirms to having regular physical and
dental checkups.
Past Medical History
Patient had no major medical events in the past except for tonsillectomy around the age
of eight. Patient does not smoke and has approximately eight drinks a month. Patient states that
he has undiagnosed allergies but is not sure to what specific agents. Patient believes to have
contact dermatitis and psoriasis at the hairline. Patient is also allergic to sulfa drugs.
Family Medical History
Patient’s maternal grandfather was diagnosed with prostate cancer but died due to CHF
complications at the age of 94. Patient’s maternal grandmother had a “medically induced
diabetes” when she was in her 60s, otherwise no major health issues; She died at the age of 99.
Patient’s paternal grandfather has been diagnosed with diabetes, glaucoma, and hypertension.
Patient’s paternal grandmother has no known medical issues. Both paternal grandparents are still
living. Patient’s father has hypertension, and mother has no known medical issues; both parents
are alive and in their 60s.
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