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Define Self Care Essay

919 words - 4 pages

Comprehensive Health History Interview


University of North Carolina at Pembroke


T.J. was the patient for a comprehensive health history interview. Patient was a reliable source to answer questions and was able to recall information from recent and distant past events that were needed to complete the health history. T.J. recalled childhood illnesses and immunizations, and patient’s family history was obtained. The review of systems was discussed and documented, as well as the functional assessment. Nursing diagnoses deemed appropriate were applied for the client. A blended format of the traditional systems approach and the functional health patterns were used.

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Last Examination Date: Reports last vision exam was June 2013 where no changes in eye sight were noted.
Allergies: Denies any allergies to medications or the environment.
Current Medications: Wellbutrin 300mg xr sleep
Travel: States travelling to the Bahamas in 2009, 2011, and 2012. Denies travel to any other countries.
Family History
Reports having sister who is age 46, died in car accident. States mother is age 68, alive and well. States father is age 68 with a history of hypertension and high cholesterol. See attached family genome on appendix A for extended family history.

Review of Systems
General Overall Health State:
Skin: Denies any changes in skin or moles.
Hair: Denies any recent hair loss or changes in texture.
Nails: Denies any changes in shape, color, or brittleness of nails.
Head: Denies head injuries, dizziness, or fainting.
Eyes: Denies any blurred or double vision.
Ears: Denies any pain, drainage, excessive earwax, or changes in hearing.
Nose and Sinuses: Denies any pain, drainage, discharge, or infection.
Mouth and Throat: Denies any pain, lesions, or sores in the mouth and throat.
Neck: Denies any pain, lumps, or swelling in the neck.
Breast and Axilla: Denies any changes in breast.
Respiratory System: Denies cough, wheezing, or difficulty breathing.
Cardiovascular System: Denies any chest pain or edema. Denies having a history of heart disease, hypertension, or anemia.
Peripheral Vascular System: Denies swelling, coldness, or paresthesia. Denies any history of varicose veins or leg pain.
Gastrointestinal System:
Urinary System:
Female Genital System:

Sexual Health: active monogonous
Musculoskeletal System: wnl
Neurologic System: no deficients
Hematologic System: Denies any excessive bleeding or bruising of the skin or mucous membranes. Denies any blood transfusions.
Endocrine System: Denies history of diabetes or diabetic symptoms.
Functional Assessment
Self-Esteem, Self-Concept:
Activity/Exercise: Denies any type of exercise routine.
Sleep/Rest: States that she is able to get about 7 hours of sleep each night.

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