NRNP 6552 APN Reproductive Health

Assignment: (1- to 2-page reflection)

• In addition to your script for building a health history for this assignment, include a separate section called “Reflection” that includes the following:
  • A brief summary of your experiences in developing and implementing your script during your health history.
  • Explanations of what you might find difficult when asking these questions. What you found insightful and what would you say or do differently.

Answer

While taking a patient’s history, there’s a lot of information you need to gather in just a short amount of it

Determine the following:

1. Biographical data

 

Source of history

Name

Age

Occupation (past or present)

Marital status/living arrangement

2. Reason for seeking care and history of present health concern

Chief complaint

Onset of present health concern

Duration

Course of the health concern

Signs, symptoms, and related problems

Medications or treatments used (ask how effective they were)

What aggravates this health concern

What alleviates the symptoms

What caused the health concern to occur

Related health concerns

How the concern has affected life and daily activities

Previous history and episodes of this condition

3. Past health history

Allergies (reaction)

Serious or chronic illness

Recent hospitalizations

Recent surgical procedures

Emotional or psychiatric problems (if pertinent)

Current medications: prescriptions, over­-the­-counter, herbal remedies

Drug/alcohol consumption

4. Family history

Pertinent health status of family members

Pertinent family history of heart disease, lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, genetic disorders

5. Functional assessment (including activities of daily living)

Activity/exercise, leisure and recreational activities (assess for falls risk)

Sleep/rest

Nutrition/elimination

Interpersonal relationships/resources

Coping and stress management

Occupational/environmental hazards

6. Developmental tasks

Current significant physical and psychosocial changes/issues

7. Cultural assessment

Cultural/health-related beliefs and practices

Nutritional considerations related to culture

Social and community considerations

Religious affiliation/spiritual beliefs and/or practices

Language/communication