Comprehensive_Health_Assessment_Documentation_Form_(0717).docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment

Comprehensive_Health_Assessment_Documentation_Form_(0717).docx

This preview shows page 1 - 4 out of 12 pages.

Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:____1/1/19______Patient InformationPatient InitialsBCAge19SexFChief ComplaintRoutine examHistory of Present Illness (HPI)19 year old female presents for routine exam. No present illnesses or complaints. 7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsNo medicationsAllergiesPenicillin-hivesMedical HX (PMH)ChildhoodNo significant findingsAdultNo significant findings1
Background image
SurgicalNo surgeriesOb/GynNo significant findingsPsychiatricNo significant findingsVaccinationsFluDate: 10/2016PneumovaxDate: NoneTetanusDate: 07/2017Family HX (specify family member affected/age at death)HTN- father and paternal grandmother, still livingSocial/Environmental HXHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholismSubstance abuseBorn in: Marion NCEducation: Current College Student Occupation: unemployedFamily situation: parents divorced, not married, no childrenTransportation options: carInsurance: father’s insuranceNeighborhood: dorm at university Language/Literacy: English, literateAccess to emerging technologies: callphone, computer, internetInterests/Hobbies: reading, shopping,spending time with friends/familyReview of Systems (ROS)List findings, or check as negative.(If you have a positive finding, then describe its seven attributes inthe HPI or PMH)Concerning SymptomFindingsGeneralWgt Δ; weakness; fatigue; feversNegative SkinRash; lumps; sores; itching; dryness; Negative2
Background image
color change; Δ in hair/nailsHeadHeadache; head injury; dizzinessNegativeEyesVision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotomaNegativeEarsHearing Δ; tinnitus; earaches; infections; dischargeNegativeNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsNegativeThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarseNegativeNeckLumps; swollen glands; goiter; pain; neck stiffnessNegativeBreastsLumps; pain; discomfort; nipple dischargeNegativePulmonaryCough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic painsNegativeCardiacChest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edemaNegativeG/IAppetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intoleranceNegativeUrinaryFrequency; nocturia; urgency; dysuria;hematuria; incontinenceMALES: caliber of urinary stream; hesitancy; dribblingNegativeG/U (General)Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposureNegativeMale G/UDischarge from or sores on penis; testicular pain/massesNAFemale G/UMenarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMPVaginal discharge; itching; sores;
Background image
Image of page 4

You've reached the end of your free preview.

Want to read all 12 pages?

  • Spring '16
  • Shelley Ashby
  • Nursing, HPI

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes