Health History Running Head: COMPRENSIVE HEALTH HISTOR PAPER

Co!"rehensi#e Health History Pa"er Helen M$%onald RN State &ni#ersity o' Ne( or) Institute o' Te$hnology &ti$a Ro!e

Health History Demographics Na!e: R+H Address: 1,,- Central A#e. Al/any N 1**-0 SS1 1111111111 Marital Status: Single Ra$e: Cau$asian Religion: Catholi$ %O2: -34-345Su""ort Person: Eli6a/eth %o(ns Informant/ Reliability: Patient noted to /e a relia/le historian7 CC: 8I9! here 'or a /iannual "hysi$al7: HPI: Patient is a ;3 year<old (ho states his last "hysi$al (as August o' *--5 /y his "ri!ary $are "hysi$ian. %r Hoen6s$h. = Pali$ades a#enue Al/any. Ne( or)7 Patient states he has /een in his usual state o' health at this ti!e7 Patient states he has no health related "ro/le!s or health $on$erns at this ti!e7 Patient states his attitude to(ard health !aintenan$e. "ra$ti$es and $on$e"t o' health is 'air7 Patient states he has /iannual "hysi$als and has dental $he$)u"s e#ery si> !onths7 Patient states he does not engage in daily health !aintenan$e "ra$ti$es7 Patient does state he does not !aintain a healthy diet or e>er$ise "attern7 Patient rates his sel'<heath a , on a s$ale o' 1<1-7 Patient denies history o' heart disease. dia/etes. hy"ertention ?HTN@. $an$er ?Ca@. and stro)e7

Health History

Past Medical History: Aeneral Health: Patient states his last "hysi$al (as August *--57 Patient states he (as /orn at Al/any Medi$al Hos"ital in Al/any N 7 Patient states there (ere no $o!"li$ations (ith his /irth7 Patient states he (as $ir$u!$ised /e'ore dis$harge a'ter /irth7

Medi$al Illness: Patient states he has a history o' )idney stones7

Surgeries: Patient states he 'ra$tured his right ti/ia and 'i/ia in the su!!er o' *--5 a'ter 'alling "laying so't/all7 Patient states he (aited until the ne>t !orning to go to Al/any Me!orial Hos"ital in Latha! N 7 B<rays (ere "re'or!ed and "atient (as s$heduled to see an ortho"edi$ surgeon as an out"atient7 Patient (as seen and e>a!ined /y %r7 Hendder!en at the 2one and +oint Center in Al/any N 7 Patient had an O"en Redu$tion Internal Ci>ation ?ORIC@ o' his right ti/ia 'i/ia 'ra$ture one (ee) a'ter /eing seen in the ER7 Patient states this (as an out"atient "ro$edure "re'or!ed at the 2one and +oin Center7 Patient states he (as seen /y "hysi$al thera"y 'or three !onths and used $rut$hes 'or t(o and a hal' !onths7

InDuries4a$$idents: Patient states he has 'reEuent right shoulder dislo$ations a'ter a 'all during so't/all7 Patient states he 'ra$tured his right ti/ia and 'i/ia in the su!!er o' *--5 a'ter 'alling "laying so't/all7

Health History Hos"itali6ations: Patient states he (as hos"itali6ed No#e!/er o' *--0 at Al/any Me!orial hos"ital in Latha! Ne( or) 'or )idney stones7 Patient states the stone (as surgi$ally re!o#ed7 Patient states he (as only hos"itali6ed on$e and ad!itted 'or less then t(enty<'our hours7

Trans'usions: Patient denies history o' trans'usions7

Psy$hiatri$ Illness: Patient states he has an adult history o' an>iety and de"ression7 Patient states he has /een ta)ing Cele>a =-!g /y !outh daily 'or de"ression7

Childhood %iseases: Patient states he had the $hi$)en "o> in 13537 Patient states he had allergies diagnosed (ith en#iron!ental allergies o' 'resh $ut grass. dust. "ollen and !old in 135F a'ter /eing seen /y an allergist7 Patient states his sy!"to!s (ere 'a$ial. eye and throat s(elling7 Patient states he did not ha#e an ana"hyla$ti$ rea$tion7 Patient states he had to re$ei#e a series o' inDe$tions 'or his allergies on$e a (ee) 'or eight years7 Patient states he does not re$all (hat the inDe$tions (ere7 Patient states he does not re$all (ho the do$tor (as or (here he (as seen7

I!!uni6ations: Patient states he has had all a""ro"riate i!!uni6ations 'or date and age in$luding "olio. MMR and Td7 Patient denies re$ei#ing the he"atitis 2 series. 'lu and "neu!onia #a$$ines7 Patient states he had a negati#e PP% August *--57

Allergies: Patient states he has no )no(n drug allergies7 Patient has en#iron!ental

Health History allergies to dust. !old. and "ollen

Medi$ations: Patient (as seen /y his "ri!ary $are "hysi$ian. %r Hoen6s$h. (ere he (as gi#en a "res$ri"tion 'or 'le>irl 0!g "o /id "rn 'or shoulder "ain7 Patient $ontinues to ta)e 'le>irl 'or "ain to this date7 Patient states he ta)es o#er the $ounter ?OTC@ i/"ro"hen as needed 'or "ain7 Patient states he ta)es Ne>iu! OTC as needed 'or heart/urn7 Patient denies any other "res$ri"tion or o#er the $ounter drug use7

Ca!ily History: Patient denies 'a!ily history o' heart disease. hy"ertention. dia/eties. and stro)e7 Patient states his "aternal grand'ather (as 5F (hen he died 'ro! lung $an$er due to s!o)ing7 Patient states his "aternal grand!other (as F1 (hen she died o' natural $auses. and is un)no(n (hen or ho( she died7 Pt states she had no health history )no(n to the "atient7 Patients !aternal grand'ather (as ,0 years old (hen he died 'ro! lung $an$er due to s!o)ing7 The "atient noted no other health history7 Patient9s !aternal grand!other died at 5* years o' age due to ly!"ho!a7 She had a history o' lu"us7 Patients 'ather is ,;. ali#e and (ell7 Patients 'ather has t(o sisters. 0=. 0F7 2oth are ali#e and (ell7 Patients 'ather also has a /rother (ho is ,5. ali#e and (ell7 Patients !other is ,; and has a history o' $hroni$ o/stru$ti#e "ul!onary disease ?COP%@ $hroni$ /ron$hitis. /reast $an$er. le't radi$al !aste$to!y. osteoarthritis. o/esity. al$ohol a/use and s!o)ing7 Patients !other has t(o sisters. ,- and 0F years o' age7 2oth are ali#e and (ell7 Patient has an ado"ted /rother7 See a""endi> A 'or detailed genogra!7

Personal-Social History

Health History A$ti#ities o' daily li#ing: -,--< Ga)e u" and sho(er -5--< 2egin (or) -3--< *- !inute lun$h /rea) 1=;-< ;- !inute lun$h /rea) 10;-< Lea#e (or) and go ho!e 1,--< Errands and $hores 13--< %inner *---< Gat$h tele#ision. read or Internet use **;-< Ao to /ed

A$ti#ity4e>er$ise: Patient enDoys "laying so't/all on$e a (ee) during the s"ring and su!!er !onths7 Patient (at$hes tele#ision. reads and "arti$i"ates in 'antasy 'oot/all and /ase/all leagues7 Patient states he does no 'or!al e>er$ise7

Nutrition: *= hour dietary re$all One $u" o' deli tur)ey one t(o "ea$es o' (hite /read (ith lettu$e. t(o sli$es o' to!ato. and s!all a!ount o' onions7 Patient also had a 'i#e oun$e /ag o' original Lays "otato $hi"s. three li'e (aters. one English !u''in (ith I Cant 2elie#e its Not 2utter. three $hi$)en 'aDitas (ith hal' a $u" o' $hi$)en. H $u" o' $heese. H $u" o' "e""ers. s!all a!ount o' onions and H $u" o' (hite ri$e (ith s!all a!ount o' salsa. a ;* o6 $o''ee (ith t(o $rea!s and t(o sugars7 Patient sates he is 'i#e 'oot nine in$hes tall and (eighs 1,0 "ounds7 Patient9s

Health History 2ody Mass Inde> ?2MI@ is *=7;,7 The "atient is o' healthy (eight7 Co!"aring the "atients *= hour dietary inta)e to the 'ood "yra!idI Patient is su''i$ient in grain inta)e7 Cood "yra!id suggests ,o6 o' grains and !a)e hal' your grains (hole7 Patient is la$)ing in #egeta/le inta)e7 The 'ood "yra!id suggests *70 $u"s "er day7 Patient is la$)ing in 'ruit inta)e7 Patient has had no 'ruit inta)e7 The 'ood "yra!id suggests * $u"s "er day7 Patient is la$)ing in !il) and $al$iu! inta)e7 The 'ood "yra!id suggests ; $u"s "er day7 Patient is su''i$ient in !eat inta)e7 The 'ood "yra!id suggests 0 J o6 e#ery day7 Patient is su''i$ient in inta)e o' (ater7 The 'ood "yra!id suggests ,. Fo6 glasses o' (ater "er day7

Ha/its: Patient drin)s one ;* oun$e $o''ee "er day7 Patient s!o)es a/out ten $igarettes "er day 'or the "ast *; years. 1F; "a$) years7 Patient states he stated s!o)ing (hen he (as 1, years o' age7 Patient states he has tried to Euit se#eral ti!es unsu$$ess'ully7 Patient states he drin)s si> to t(el#e al$oholi$ /e#erages on$e "er (ee)7 Patient states he drin)s T(isted Tea7 Patient denies street drug use7 Patient (as $on#i$ted o' three dri#ing (hile into>i$ated ?%GI@ !isde!eanors in 1331. 133F. and *--57 Patient (as "la$ed in Al/any County Corre$tional Ca$ility in *--5 'or se#en days /e$ause o' his se$ond %GI and in *--3 'or #iolation o' "ro/ation7 Patient $urrently attends "ro/ation on$e e#ery other (ee) at Al/any County Pro/ation de"art!ent. Pearl Street in Al/any Ne( or)7 Patient is $urrently in the Saint Peters Addi$tion Re$o#ery Center "rogra! 'or al$ohol a/use. Central A#e in Al/any Ne( or)7 Patient states he uses a seat/elt e#ery ti!e he is a !o#ing #ehi$le7 Patient states he en$ourages all others in the #ehi$le to (ear seat/elts7 Patient states he does not dri#e

Health History and does not ha#e a !otor #ehi$le li$ense7

Psy$hologi$al4!ental status: Patient states he /elie#es he dresses a""ro"riate 'or age and en#iron!ent7 Patient states he li)es to stay (ell<groo!ed e#eryday7 Patient states he /elie#es his !anors are a""ro"riate 'or his $ulture7 Patient states his (orries are !ini!al7 Patient9s goals in$lude getting !arried to his 'ian$K in Se"te!/er o' *-1- and !aintaining a good relationshi"7 Patient states his sel'<$on$e"t is good7 Patient is in the de#elo"!ental stages o' young adult: inti!a$y #ersus Isolation. a$$ording to Eri)son7 The "atient e>"resses e!otion and trusts enough to o"en u" to others7 The "atient "resents (ith al$oholis!7 The "atient is still $urrently li#ing (ith his !other /ut sol#es "ro/le!s o' li'e that a$$o!"anies inde"enden$e 'ro! her7 The "atient has a $lose and inti!ate relationshi" (ith a "artner7 He has a so$ial grou" o' 'riends7 The "atient has a long<ter! Do/ and $ontri/utes to his 'a!ily7 ?Ge/er. Lelley *--5@ Patient uses reading. (at$hing tele#ision. doing 'antasy 'oot/all and /ase/all. and hanging out (ith 'riends and 'a!ily and drin)ing as stress redu$tion te$hniEues7 Patient is $urrently in the SPARC "rogra! 'or al$ohol $ounseling7

Marital: Patient is $urrently engaged to his girl'riend sin$e May o' *--57 Patient states his relationshi" has /een on and o''7 Patient states his relationshi" /e$a!e serious in %e$e!/er o' *--3 a'ter he (as in Dail7 Patient has /een engaged sin$e August o' *--37 Ca!ily: Patient $urrently li#es (ith his !other and hel"s her out (ith $hores around the house7

Health History So$ial: Pt states he has e>tensi#e 'riends and )ee"s in $lose $onta$t (ith the! through Ca$e/oo) online7 Pt states he has $lose relationshi"s (ith his 'ian$K. !other and 'ather7 Patient states he gets along (ith "eo"le (ell7 Patient states he gets along (ith his $o(or)ers 'air and o$$asionally gets into #iolent #er/al argu!ents (ith the!7

O$$u"ational: Patient has /een (or)ing as a !a$hine o"erator at I!"erial "ools and s"as 'or the "ast 1F years7 Patient states he is on his 'eet 'or !ost o' the day at (or) $arrying 10<;- "ounds o' !aterial 'reEuently7 Patient states he does not (or) around ha6ardous !aterials7 Patient o"erates large !a$hines that $ut and sha"e !edal and $an /e dangerous to (or) (ith7 Patient states he uses goggles during (or)7 Patient states he does not (ear glo#es. steel<toed shoes or a hel!et7 Patient denies (earing "rote$ti#e $lothing7 Patient states he has so!e stress at (or) asso$iated (ith !ore res"onsi/ility due to seniority7

Cinan$ial: Patient states his annual in$o!e is a""ro>i!ately ;0.--- dollars "er year7 Patient states his in$o!e is adeEuate 'or li'estyle7 Patient states he has a "ersonal sa#ings a$$ount and a Doint (edding sa#ings a$$ount (ith his 'ian$K7 Patient states he has no $redit $ards and states his $redit history is 'air7

Edu$ation: Patient graduated 'ro! South Colonie High S$hool in 13F3 (ith his high s$hool di"lo!a7 Patient states he (ent to the &ni#ersity o' Mississi""i a'ter high s$hool 'or one year 'or s"orts !edi$ine and "hysi$al edu$ation7 Patient states he de$ided not to 'inish /e$ause he (as too 'ar a(ay 'ro! ho!e7

Health History S"iritual: Patient states he is $atholi$7 Patient states he no longer attends $hur$h /ut /elie#es in Aod7 Patient states he (as /a"ti6ed. had his 'irst $o!!union and (as $on'ir!ed7

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Cultural: Patient states he doesn9t )no( ho( !any generations o' his 'a!ily are in the &nited States7 Patient states his is o' Irish and Aer!an de$ent7 Patient states his $ultural /a$)ground has no a''e$t on his health $are "ra$ti$es7

Ho!e and Neigh/orhood: Patient states he li#es in a t(o</edroo! a"art!ent (ith his !other on Central A#enue in Al/any7 Patient states there are 10 ste"s to get to his a"art!ent on the se$ond 'loor7 Patient states there is one other a"art!ent in his /uilding (ith #a$ant o''i$e s"a$e on the 'irst 'loor7 Patient states he has ele$tri$ heat. one landline "hone and no "ets7 Patient states he has a li#ing roo!. 'ull si6ed /ath and )it$hen (ith sto#e. !i$ro(a#e o#en and 'ull si6ed re'rigerator7 Patient states he has no laundry 'a$ilities in his a"art!ent7 Patient states that he is (ithin (al)ing distan$e o' stores. s$hools and do$tors o''i$es7 Pt states the $losest hos"ital is Al/any Me!orial Hos"ital in Latha!7 Patient states he only has one neigh/or in his a"art!ent /uilding that re$ently !o#ed into the /uilding7 Patient states he has t(o 'ire e>its to his a"art!entI the !ain entran$e and a !etal ladder o'' the /a$) "or$h7 Patient states his a"art!ent has t(o s!o)e dete$tors and a 'ire e>tinguisher in the !ain hall(ay7

En#iron!ental: Patient states he has #illage (ater su""ly and has a 'lushing toilet in his /athroo!7 Patient states there is trash re!o#al on$e a (ee) "ro#ided /y the landlord7

Health History

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Patient states he li#es in a high tra''i$ area (ith lots o' noise 'ro! $ars7 Patient states the only )no(n "ollutants are 'ro! $ars7 Patient states he has no e>"osure to ha6ardous !aterial. radiation or "esti$ides7

Re#ie( o' Syste!s Aeneral: Pt denies 'e#er. $hills. !alaise. or 'atiga/ility7 Patient states he has /een su''ering 'ro! night s(eats. (hi$h he /elie#es is 'ro! his ne( !edi$ation Cele>a7 Patient states he has gained 10 "ounds in the last , !onths do to ina$ti#ity and /eing in a $o!'orta/le relationshi" (ith his 'ian$K7

S)in: Patient denies history o' s)in disease. rash. "ig!entation or te>ture $hanges to his s)in7 Patient states he his had u""er e>tre!ity it$hing due to the $old (eather7 Patient states he /elie#es he has /een e>"erien$ing the early stages o' !ale "attern /aldness7 Patient denies $hanges in his nails7 Pt states he uses CVS "har!a$y /rand %ry S)in Thera"y. $o!"ara/le to Eu$erin7 Pt states he uses suns$reen s"' F e#ery ti!e his is in the sun 'or e>tended "eriods o' ti!e7 Pt states he uses Sau#e sha!"oo and $onditioner on$e a day7 Pt states he uses do#e original /ody soa"7 Patient states he uses Neutrogena On<the< s"ot a$ne treat!ent as needed 'or o$$asional a$ne7 Pt states he uses a Ma$; Aillette ra6or and Aillette sha#ing $rea! on$e a day to sha#e7 Pt states he uses A$Eua %igio Aiorgio Ar!ani $ologne on$e a day7 Patient states he uses %egree s"ray deodorant to /ilateral ar!"its on$e a day7 Pt states he $li"s his nails on$e a (ee)7

Head4ne$): Pt denies heada$hes. di66iness. syn$o"e. head inDuries. lu!"s. s(ollen

Health History glands. goiter. and ne$) range o' !otion "ain or sti''ness7

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Ears: Patient denies ear "ain. dis$harge. tinnitus. #ertigo. hearing loss. use o' hearing aides7 Pt states his only e>"osure to e>$essi#e noise is at his house 'ro! hea#y tra''i$7 Patient states he uses E<ti"s to $lean his ears daily7 Patient denies history o' ear in'e$tions7

Eyes: Pt states his last eye e>a! (as during his last "hysi$al in August o' *--57 Patient states a Snellen eye $hart (as used and his #ision (as *-4*- in /oth the le't and right eye (ithout glasses7 Patient denies eye "ain. di"lo"ia. redness. tearing. and history o' glau$o!a or $atara$ts7

Nose and Sinuses: Pt denies $hanges in sense o' s!ell7 Patient states he has a $old at least t(i$e a year7 Pt denies nasal o/stru$tion. e"ista>is. and "ostnasal dis$harge7 Patient states he su''ers 'ro! seasonal allergies (ith an it$hy. stu''y nose7 Patient states he has !od a!ount o' $lear nasal dis$harge (ith allergies7 Patient denies hay 'e#er. sinus "ain and in'e$tion7

Mouth and Throat: Patient states his last dental e>a! (as Mar$h o' *--3 /y %r +a!es Aalati in Cli'ton Par) Ne( or)7 Pt states he #isits the dentists e#ery si> !onths 'or $leanings and $he$)u"s7 Patient states he /rushes his teeth t(i$e a day (ith Crest Co!"lete tooth"aste7 Patient states he $hanges his tooth/rush e#ery three !onths7 Patient states he had 'our (isdo! teeth e>tra$ted /y an un)no(n surgeon in *--,7 Patient states he has 'our !etal 'illings due to $a#ities7 Patient denies e>"erien$ing /leeding gu!s or

Health History $urrent tooth a/s$esses7 Patient denies using dentures7 Patient denies any $urrent sore throat. hoarseness or $hange in #oi$e7 Patient denies !outh odor. e>$essi#e sali#ation. dryness. ul$ers. and distur/an$es in taste or soreness o' his tongue7

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Res"iratory: Patient states he (as re$ently diagnosed on 1-4;-4-3 (ith /ron$hitis. sore throat and $ough7 Patient states he (as seen /y his "ri!ary $are "hysi$ian and (as "res$ri/ed a6ithro!ya$in7 Patient sates he is diagnosed (ith /ron$hitis at least on$e a year7 Patient denies history o' asth!a. e!"hyse!a. "neu!onia and tu/er$ulosis7 Patient denies $hest "ain. and (hee6ing7 Patient states he gets short a /reath (hen "laying so't/all7 Patient denies shortness o' /reath (hile (al)ing and ta)ing stairs7 Patient states he $oughs in the !orning due to s!o)ing and o$$asionally "rodu$es a s$ant a!ount o' yello( s"utu!7 Patient denies he!o"tysis. to>in or "ollution e>"osure7 Patient states his last !antou> (as (ith his last "hysi$al in August o' *--5 and states the results (ere negati#e7

Cardio#as$ular and "eri"heral #as$ular: Patient denies $hest "ain. history o' heart disease. high /lood "ressure. !ur!urs. "al"itations. dys"nea. ede!a. $laudi$ation. angina. and !yo$ardial in'ar$tion7 Patient denies ha#ing an e$o$ardiogra!. ELA o' other $ardia$ testing7 Patient denies leg $ra!"s. #ari$ose #eins. thro!/o"hle/itis. and ul$ers7 Aastrointestinal: Pt states his a""etite has in$reased sin$e getting engaged7 Patient denies digestion intoleran$e o' any 'ood7 Pt states he has heart/urn on$e or t(i$e a (ee) and ta)es Ne>iu! OTC one ta/ on$e or t(i$e a (ee) as needed7 Pt denies dys"hagia. nausea. #o!iting he"atitis. Daundi$e. ul$ers. gallstones. "oly"s. or tu!ors7 Patient denies "olyuria.

Health History dysuria. urgen$y. hesitan$y. di!inished strea!. in$ontinen$e and urinary disease7

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&rinary: Patient states he has a history o' )idney stones7 Pt states he (as hos"itali6ed No#e!/er o' *--0 at Al/any Me!orial hos"ital in Lathe! Ne( or) (here the stone (as surgi$ally re!o#ed7 Patient states that he has had urinary tra$t in'e$tions due to the )idney stones7 Patient states he has re$urrent 'lan) "ain. (hi$h he /elie#es is 'ro! )idney stones7 Patient states he last "assed a )idney stone in A"ril o' *--37 Patient denies groin. su"ra"u/i$ and lo(er /a$) "ain7

Male Aenital: Patient denies history o' se>ually trans!itted diseases7 Pt de$lined to state ho( !any se>ual "artners he9s had7 Patient states he has one "artner at this ti!e7 Patient "re'ers (o!en7 Patient states his se>ual interest. 'un$tion. satis'a$tion are nor!al7 Patient denies using $ondo!s and states his 'ian$K is ta)ing a daily /irth $ontrol "ill7 Pt denies history o' hernias. dis$harge. sores. or "ain in the testi$les or "enis7 Patient states he does not do sel' testi$ular e>a!s7 Patient states his last testi$ular e>a! (as during his last "hysi$al in August o' *--57 Patient states he has ne#er had a digital e>a! to $he$) his "rostate7

Mus$ulos)eletal: Patient denies history o' arthritis or gout7 Patient states he has 'reEuent right shoulder dislo$ations a'ter a 'all during so't/all7 Pt (as seen /y his "ri!ary $are "hysi$ian (ere he (as gi#en a "res$ri"tion 'or 'le>irl 0!g "o /id "rn 'or shoulder s"as!7 Pt $ontinues to ta)e 'le>irl 'or !us$le s"as! to this date7 Patient states his "ain $an /e as /ad as 5 out o' 1- on the "ain s$ale and 'eels shar"7 Pt denies any other "ain. $ra!"ing.

Health History (ea)ness. and "ro/le!s (ith gait or $oordination7 Patient denies /a$) "ain or dis$ "ro/le!s7

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Neurologi$al: Patient denies history o' sei6ure disorder. stro)e. 'ainting. /la$)outs. (ea)ness. "aralysis. nu!/ness or tingling7 Patient states he does ha#e ner#ousness. !ood $hanges and de"ression7 Patient denies $hanges in !e!ory7

He!atologi$al: Patient denies history o' ane!ia. easy /ruising or /leeding. trans'usions or rea$tions7 Patient denies e>"osure to to>i$ agents or radiation

Endo$rine: Patient denies history o' dia/etes and thyroid disease7 Patient states he has no $hanging in si6e o' head. hands or 'eet7 Patient has se$ondary se> $hara$teristi$s o' 'a$ial hair. $hest hair and "u/i$ hair7 Patient states his hair is (ell distri/uted7 Patient denies using hor!one thera"y7 Patient states he does not ha#e heat or $old intoleran$e. e>$essi#e s(eating. thirst or hunger7

Nursing Theorist: Cloren$e Nightingale9s en#iron!ental theory (as de#elo"ed in 1F,-7 The the!e o' this theory is to !eet "ersonal needs o' the "atient (ithin the en#iron!ent7 Con$ern (as "la$ed on the en#iron!ent o' the "atient7 These $on$erns in$ludeI $leanliness.

Health History #entilation. te!"erature. lighting. diet and noise7 Cloren$e Nightingale /elie#ed these $on$erns dire$tly in'luen$ed a "atient9s health and healing7 Cloren$e /elie#ed in edu$ating the nurse to redu$e "atient har! and in$rease "atient re$o#ery7

1,

N rsing Diagnosis: A$ti#ity intoleran$e related to ?r4t@ sedentary li'estyle as e#iden$ed /y ?AE2@ "atient states he is short o' /reath on e>ertion and does no e>er$ise7 An>iety r4t stress AE2 e>"ressed $on$erns due to (or) and !arriage7 %e'ensi#e $o"ing r4t $o(or)ers AE2 "t hy"ersensiti#ity to $riti$is!7 Ine''e$ti#e $o"ing r4t distur/an$e in "attern o' tension release AE2 a/use o' al$ohol and inadeEuate "ro/le! sol#ing7 I!"aired urinary eli!ination r4t )idney stone o/stru$tions AE2 "t $o!"laint o' urinary tra$t in'e$tions and no$turia7 Nutrition i!/alan$e. ris) 'or !ore than /ody reEuire!ents r4t $on$entration 'ood inta)e at the end o' the day AE2 "atient states he has gained 10 "ounds in si> !onths7 Nutritional de'i$it r4t la$) o' #egeta/le. 'ruit. !il) and $al$iu! inta)e AE2 *= hour 'ood re$all7 Chroni$ "ain r4t shoulder inDury AE2 "t states I ha#e $hroni$ shoulder "ain7 I!"aired gas e>$hange r4t s!o)ing AE2 "t state!ent o' shortness o' /reath during s"orts a$ti#ities7 Ris) 'or 'alls r4t no$turia. 10 ste"s into house. al$ohol use AE2 "atients9 state!ents during health history7 Ris) 'or trau!a r4t drun) dri#ing AE2 "t states he has had three %GI9s7

Health History Ris) 'or trau!a r4t "otential house 'ires AE2 "t states he s!o)es inside7 Ris) 'or trau!a r4t e>"osure to dangerous !a$hinery AE2 "t states he does not (ear "rote$ti#e de#i$es su$h as hel!et. glo#es. steel<toed shoes7

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Ris) 'or other<dire$ted #iolen$e r4t threats to $o(or)ers AE2 "t states he has had #er/al argu!ents (ith $o(or)ers7 I!"aired #er/al $o!!uni$ation r4t altered "er$e"tions due to al$ohol a/use. e!otional $onditions su$h as de"ression AE2 "t states he uses al$ohol7 Readiness 'or enhan$ed $o!!uni$ation r4t e!otional an>iety and de"ression AE2 "atient states he "arti$i"ates in SPARC7 Ine''e$ti#e $o"ing r4t inadeEuate "ro/le! sol#ing AE2 al$ohol a/use7 Readiness 'or enhan$ed $o"ing r4t so$ial su""ort and resour$es a#aila/le AE2 "t states he attends SPARC7 Health<see)ing /eha#iors r4t s!o)ing $essation and so/riety AE2 "atients e>"ressed desire to see) higher le#el o' (ellness7 Non$o!"lian$e r4t "ersonal a/ilities to re!ain so/er AE2 "atient $ontinues to drin) al$ohol (hile attending SPARC7 Ris) 'or o/esity. lung Ca. COP%. and osteoarthritis r4t 'a!ily history AE2 genogra!7 Ris) 'or s)in $an$er r4t inadeEuate suns$reen lotion AE2 "t states he uses s"' 1 F7

Health History

1F

Re'eren$es %oenges. M7. Moorhouse. M7. geissler<!urr. A7 ?*--=@ Nurses Pocket Guide. Philadel"hia: C7A7 %a#is Co!"any7 Ge/er. +7. Lelley. +7 ?*--5@ Health Assessment in Nursing. third edition7 Philadel"hia: Li""in$ott Gillia!s M Gil)ins7 R7+7 Hotaling ?"ersonal $o!!uni$ation. No#e!/er *. *--3@

Health History Hood. L7. Leddy. S7 ?*--,@ Conceptual Bases of Professional nursing. Philadel"hia: Gillia!s M Gil)ins7

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