NURSING NR 302/ RUA Health History Health Assessment(Chamberlain College of Nursing)

RUA Reflection of The Health

History Name…………………..

Chamberlain College of

Nursing NR302: Health

Assessment I January

2020/2021




pg. 1

, HEALTH HISTORY ASSESSMENT 2




Data
Collection
Date:
01/07/2020
Birth date
Client Initials: M. C. Gender: Female and Month:
01/25
Marital status: Single
Date of last
physical exam:
Race: Caucasian Patient States her
“last physical was
in March of 2019.”
Primary Language: English
Source of
Occupation: Practice Manager of an
Information:
Urgent Care
Patient

REASON FOR SEEKING CARE
Patient has come to Chamberlain Hospital seeking care for “consistent diarrhea.”


PRESENT HEALTH/HISTORY OF PRESENT ILLNESS


PALLIATIVE/PROVOCATIVE: Patient states “nothing helps my upset stomach.”
Patient states “my stomach is more upset after eating.”

QUALITY:

Patient states “there is a constant
dull pain in my lower stomach and
my stool is sometimes green not
brown.”

REGION/RADIATING:

Patient states her pain “is in the
lower left side of her stomach
and her middle back area.”

SEVERITY:




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