NR 302 Health Assessment I Health History RUA paper

Student Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name

Date

Demographic Data

L.S. is a 23-year-old Caucasian female, born on February 4, 1993, in Baltimore, Maryland. Her primary language is English, though she possesses basic proficiency in Spanish. She completed her high school education in 2011 and currently resides in Salisbury. L.S. balances her academic commitments with her role as a veterinary receptionist/technician. She lives with her boyfriend and his parents while saving to transition to independent living. She reports experiencing frequent headaches, which are managed with over-the-counter medication as needed.

Health Perception

L.S. acknowledges her overweight status but demonstrates proactive engagement in maintaining her physical health. She monitors her diet closely and has incorporated regular running into her routine, training for an upcoming marathon scheduled within the next few months. Despite identifying as overweight, she perceives her overall health as good and remains committed to her current regimen to ensure peak performance during the marathon.

Past Medical History

L.S. occasionally consumes alcohol on weekends but does not smoke. She has no significant history of hospitalizations. During high school, she was diagnosed with shin splints due to soccer activities. To manage her headaches, L.S. takes 200 mg of Ibuprofen as needed. Overall, she maintains a proactive approach to her physical health and preventive care.

Family History

Category	Description	Details
Paternal Grandparents	Education	Both are high school graduates.
	Health History	Grandfather, a retired firefighter, was diagnosed with diabetes at 73 and experienced a heart attack at 75. Grandmother underwent spinal surgery in 2015 but remains otherwise healthy.
Maternal Grandparents	Education	Both were high school graduates.
	Health History	Deceased. Grandmother smoked until age 25 and died of lung cancer due to poor circulation. Grandfather, a Navy Seaman and heavy drinker, died from bladder and prostate cancer.
Parents and Siblings	Mother	Holds a Bachelor’s Degree, employed as an IT Manager at the U.S. Census Bureau, and has no significant health issues.
	Father	Bachelor’s degree holder, IT Specialist at the Department of Defense, with hypertension, obesity, pre-diabetes, migraines, and chronic sinusitis.
	Siblings	One brother experienced a heart attack at 41 and was later diagnosed with colon and liver cancer at 58. Another brother has type 2 diabetes.

Review of Systems

The interview with L.S. was conducted at a local coffee shop, providing a relaxed and informal environment. She appeared comfortable and engaged throughout the discussion, responding openly to questions. The informal setting fostered rapport, allowing trust to develop and facilitating candid communication. Although initial nervousness was noted on my part, thorough preparation and the application of class-learned skills ensured the interaction proceeded smoothly. One observation was a tendency to rely on closed-ended questions, which limited opportunities for deeper discussion. Incorporating more open-ended questions in future assessments could enhance the quality of information gathered.

Reflection

The interview with L.S. was both informative and engaging. Conducting it in a setting of her choice contributed significantly to her comfort and willingness to share personal information. The experience highlighted the importance of preparation and the strategic use of learned techniques to build trust and rapport. Although the interview progressed effectively, reliance on closed-ended questions was noted, suggesting a need to implement more open-ended questioning in future encounters. Post-interview, I recommended that L.S. explore additional resources on diabetes management and nutritional guidelines. She demonstrated genuine interest in understanding these topics, indicating motivation to support her long-term health and wellness goals.

References

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.

Brown, C., & Smith, J. (2022). Health assessment across the lifespan (5th ed.). New York, NY: Pearson.

NR 302 Health Assessment I Health History RUA paper

Taylor, K. (2021). Family history and preventive health: Guidelines for nursing practice. Journal of Nursing Practice, 35(2), 145–158.