RUNNING HEAD: HEALTH HISTORY AND ASSESSMENT 1
NR 304
Health History and Health Assessment
Chamberlain University College of Nursing
NR 304: Health Assessment II
Demographic Data
J. F. is a 42-year-old caucasian female. She was born on February 20, 1978, in the St.
Louis region. J. F. lives comfortably in her previous childhood home in Chesterfield, MO. J. F. is
married, with two children; 22 and 17. She works as a count administrator and works Monday
through Friday from 8 am - 4:30 pm.
Reason for Care
J. F. came into the emergency room for seeking care is due to a severe headache. She has
been managing her symptoms at home for the past four days. J. F. has tried many over the
counter medications and her prescription migraine medication but resulted in little relief. J. F.
expressed that the pain makes her feel nauseous and makes her vomit. She states that she is
unable to do her normal daily activities, and her dietary intake has decreased.
Present Illness
J. F.'s present illness is a migraine and dehydration. J. F. reports that the pain associated
with her migraine makes her nauseous, which sometimes leads to vomiting. As a result of not
being able to keep any food or drink down, J. F. has become dehydrated, and her level of fatigue
has increased.
Perception of Health
, HEALTH HISTORY AND ASSESSMENT 2
J. F. believes that being healthy includes eating healthy, having the energy to engage in an
activity, and maintaining a healthy sleep schedule. She finds unhealthy as being obese, eating
fast food frequently, drinking regularly, and long time smokers. J. F. feels that she fits in the
healthy range; however, she wishes she would work out more. She reports difficulty in increasing
her exercise due to the pain associated with rheumatoid arthritis.
Past Medical History
J. F. was diagnosed with allergies as a child. At this time is when she found out that she
was allergic to shellfish. Shellfish causes J. F. to have a rash, break out in hives and gives a
tingling sensation in the back of her throat. As a child, J. F. received allergy shots. She does not
remember how long they lasted, but she knows it was more than two years. When J. F. went into
labor with her second child, it was considered an emergency. She found out that her uterus
ruptured, which put her life in danger and her baby as well. J. F. reports they completed the
cesarian with no complications. She reports getting bronchitis more than once in a year as a
child. As she aged, the frequency of her bronchitis decreased and now rarely ever gets sick. J. F.
reports a hernia surgery as a child as well. She states that she takes xeljanz (rheumatoid arthritis
medication) daily along with supplemental vitamins.
Family Medical History
J. F. has an older sister. Her older sister also had a hernia repair surgery as a child. J. T.
reports that her sister had a sinus infection about as frequently as J. T. had bronchitis. Her sister
has seasonal allergies, headaches, and takes medication for hypothyroidism. She expresses that
her mother has arthritis in her hands and suffers from osteoporosis. Her mother also has
decreased visual acuity and requires a high strength prescription to see. J. T. reports that her
father died a year ago from a heart attack. Before then, he was diagnosed with early-onset
NR 304
Health History and Health Assessment
Chamberlain University College of Nursing
NR 304: Health Assessment II
Demographic Data
J. F. is a 42-year-old caucasian female. She was born on February 20, 1978, in the St.
Louis region. J. F. lives comfortably in her previous childhood home in Chesterfield, MO. J. F. is
married, with two children; 22 and 17. She works as a count administrator and works Monday
through Friday from 8 am - 4:30 pm.
Reason for Care
J. F. came into the emergency room for seeking care is due to a severe headache. She has
been managing her symptoms at home for the past four days. J. F. has tried many over the
counter medications and her prescription migraine medication but resulted in little relief. J. F.
expressed that the pain makes her feel nauseous and makes her vomit. She states that she is
unable to do her normal daily activities, and her dietary intake has decreased.
Present Illness
J. F.'s present illness is a migraine and dehydration. J. F. reports that the pain associated
with her migraine makes her nauseous, which sometimes leads to vomiting. As a result of not
being able to keep any food or drink down, J. F. has become dehydrated, and her level of fatigue
has increased.
Perception of Health
, HEALTH HISTORY AND ASSESSMENT 2
J. F. believes that being healthy includes eating healthy, having the energy to engage in an
activity, and maintaining a healthy sleep schedule. She finds unhealthy as being obese, eating
fast food frequently, drinking regularly, and long time smokers. J. F. feels that she fits in the
healthy range; however, she wishes she would work out more. She reports difficulty in increasing
her exercise due to the pain associated with rheumatoid arthritis.
Past Medical History
J. F. was diagnosed with allergies as a child. At this time is when she found out that she
was allergic to shellfish. Shellfish causes J. F. to have a rash, break out in hives and gives a
tingling sensation in the back of her throat. As a child, J. F. received allergy shots. She does not
remember how long they lasted, but she knows it was more than two years. When J. F. went into
labor with her second child, it was considered an emergency. She found out that her uterus
ruptured, which put her life in danger and her baby as well. J. F. reports they completed the
cesarian with no complications. She reports getting bronchitis more than once in a year as a
child. As she aged, the frequency of her bronchitis decreased and now rarely ever gets sick. J. F.
reports a hernia surgery as a child as well. She states that she takes xeljanz (rheumatoid arthritis
medication) daily along with supplemental vitamins.
Family Medical History
J. F. has an older sister. Her older sister also had a hernia repair surgery as a child. J. T.
reports that her sister had a sinus infection about as frequently as J. T. had bronchitis. Her sister
has seasonal allergies, headaches, and takes medication for hypothyroidism. She expresses that
her mother has arthritis in her hands and suffers from osteoporosis. Her mother also has
decreased visual acuity and requires a high strength prescription to see. J. T. reports that her
father died a year ago from a heart attack. Before then, he was diagnosed with early-onset
