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Chamberlain College of Nursing NURSING NR 304NR304 Health assessment.(Health History Chamberlain University College of Nursing NR 304: Health Assessment II April 12th, 2021)

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Health History Chamberlain University College of Nursing NR 304: Health Assessment II April 12th, 2021 2 Heath History For this assignment, I will be conducting a health assessment interview on ... a friend. The health assessment discusses demographics, perception of health, medical history, review of systems, and more. My patient happily agreed to share his health information and will use NW as his initials. Heath History Demographics Data NW is a 24-year-old Caucasian male of Italian and German descent who grew up in Royal Oak Michigan. His primary language is English and knows some Italian. He is currently in a healthy relationship as he describes for seven years and they live together in a house. He works 40 hours a week in Detroit as a police officer for about four years. His job provides health, dental and vision insurance. This allows him to see a doctor regularly. Reason for Care The patient is not admitted but comes in today for a routine physical with his primary care provider for work. No present illness but if there was one I would assess further by using the PQRST. P represents proximity and I would ask what makes it better or worse. Q is quality and I would ask my patient what does it feel like. R is region or radiation as in does in spread anywhere. S is severity as in how bad, and lastly is T for time or onset. Perception of Health NW defines health as “Taking care of yourself both inside and out which includes both mental and physical qualities.” He continues by saying how important self-care is and how it can affect his health positively especially in the job he’s in. As of now, NW views his situation as “good” with having no complaints about health. His biggest concern today is trying to find a 3 balance between work, friends, family, and time for himself. NW worries that in the future work will pick back up and he will have no time for himself or will have to cut that time in half. NW’s health goals include him getting in shape, eating healthier, and gaining fifteen pounds. He expects providers to keep his medical history confidential and provide clear instructions at discharge. Past Medical History NW had many ear infections as a child. Recently tested positive for Covid-19 March 2021 but has made a full recovery since then. No chronic illnesses or diseases. He states that immunizations are all up to date including the Covid vaccine. Yearly TB test and flu shot since starting his job four years ago. The patient had a few accidents when he was younger which include minor injuries as cuts and bruises from playing sports. No major or traumatic injuries. NW reports no medication or food allergies. No hospitalizations, surgeries, or operations. Current medications include a vitamin C gummy once daily. BMI is within normal limits. [Show More]

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