Case Study: Health History Assessment


According to (D’Amico, 2011), health assessment to be a patient means the systematic way of collecting client’s data, with an aim of determining his/her current health status, the health risk they may be exposed to, and identifying the health practice activities to be done to improve the patient’s health status. It can also refer to the intentional and interactive process by which nurses critically collect, and analyses and digests the relevant collected information form the patient to judge their the status of their health. In this essay, I shall present a health history assessment on an old aged patient and therefore there will be the need to make use of Comprehensive Health Assessment (CAH), which is a clinical practice relevant for the elderly patients. (Agedcare, 2013), states that the elderly are exposed to more sensitive medical and social issues in terms of the care requirements, therefore requires Comprehensive Health Assessment, that ensures skilled staff that will ensure care to the patient. My patient was elderly Ms. Pamela Jackson, and therefore, for the assessment, I was interested in demographic data, the patient’s perception on health, past medical history, both for the patient and the lineage family, and some other information about the patient.

Demographic Data

The demographic data in an assessment include the birth year, the gender, country they come from and if there are, many ethnic groups then which one does the patient belong. Ms. P.K was 86 years old by last year when I assessed her. She is currently living in New York but she was born in South Carolina. Pamela lives in third floor, on a story building but used an elevator, in a one-bedroomed house, and her children supports her financial, while for social security and Medicare she receives form the government.

Perception of Health

World Health Organization (WHO) (2014) defines health as the state of being mentally, physical, and socially well and it is not merely the idea of not having any disease. In this case, the elderly usually do not feel comfortable as they feel lonely, with nobody with them to help them go through. The patient describes the pain that she goes through when the chest pain begins and hopes that things could have been different if she were healthy. The patient loves other activities, and normally still strong when she feels healthy. She could go to the farm, walk her dog around and after these activities she could relax. Pamela usually feels that the chest pains and these illnesses normally takes this fun away from her, and usually feel bad about it. She occasionally feels that she is already old and therefore, she does not deserve to suffer that way instead she can die. Feeling of social disconnectedness from the other family members who she cannot visit normally, however, sometime they make feel healthy and loved. Therefore, Pamela says that nowadays she loves her life and has a change of perception towards being healthy.

Past Medical History

In 1964, she had some surgical procedures done on her, the first one involved, total abdominal hysterectomy that included the removal of uterus including the cervix, this surgery is done for women through their vaginas when they are faced with conditions such endometrial hyperplasia, uterine prolapse, or cervical dysplasia. This was highly relevant for Pamela because she was suffering from dysplasia. Five years later, she had another surgery, bunionectomy. This type of surgery helps in the removal of bunion, which is an enlargement experienced at the joint base of a big toe and it is normally comprised of the soft tissue and the bone. Pamela was experiencing irritation on her legs by then, and she had no fitting shoe, therefore had go through with surgery (Bunionectomy, 2000).

The same year that she had bunionectomy, is the same year that she was diagnosed with hypertension, and this was the time her problems started. She was administered some drugs that currently she remember which ones, but she can think about is that she stopped using them after 3 months because they had a side effect on her body, as they were causing drowsiness to her. Some years later, she was diagnosed with peptic ulcer disease, but for this she was administered specific drugs, and that is, cimetidine that helped her resolve the problem within 4 months’ time. Pamela does not have history of other illnesses such as heart disease, lung disease, nor cancer.

She had allergies when she was administered penicillin back in 1965; the drugs caused rashes on her body and hives. Therefore, she is normally advised not to use penicillin or to be used on her by any other medical specialist. She also have a social history of using alcohol, she has two beers every weekend with some wines when having dinner. She had no prescription for illegal drug use, as she never used tobacco related drugs.

Family Medical History

Pamela did not have the chance to grow up in the care of her mother as she died at the age of 40, leaving Pamela very young, that her aunt decided to take of her until she grew old. The cause of death for her mother was kidney failure. Her father is also deceased, and the cause of his death was a heart attack, that stroke him and he was gone. Pamela has been feeling that alone as her husband died too, he suffered from pneumonia and seizures. The old woman does not have any sisters, but was blessed with four daughters who are all well, but the son also died and was suffering from pneumonia. Her family therefore has a history of hypertension but no diabetes or cancer. Her family members do not have any habit of alcohol use or smokers only use alcohol during occasions.

Review of Systems

Starting from the top of her body to the bottom, she was interviewed on how she feels about every part. The standard body energy of the body should good, the weight stable at 160 Ibs, and the standard height 5’8”2. Given the age of the patient, her eyesight began to be blurry and this required her to wear reading glasses, but she has no diplopia or any other eye pain. The age Pamela makes her earing capabilities reduced, and therefore, for so many years, she has been experiencing hearing loss, hence she has to use hearing aid. Nose: she has no history of tonsillectomy, and has been wearing full set of dentures for many years and it has been working well for her, she has had no obstruction. She has no history of pleurisy, asthma, or coughing in her respiratory systems.

By 1960, she was admitted of hematemesis and melena, which means vomiting of blood and discharge of black stool with blood (Wilson, 1990). Her endoscopy showed some evidence of gastritis and therefore received units of packed cells; this helped make her stool brown. Pamela has had a history of cystitis, E Coli, but was treated using Bactrim. She had five pregnancies, with four successful and one miscarriage had her menopause at the age of 50. In terms of neuromuscular part, she experienced osteoarthritis on the shoulder, hips, and all of her knees for at least 20 years. Pamela did not have histories of anxiety and emotional distress, depression, no blood clotting.

Developmental Considerations

According to (Hoffman, 2001), development is a component in the healthcare across all the lifespan; therefore this gives advantage to the healthcare professionals to take care of their clients. Erickson states that in each stage of development there are different tasks that should be considered and this ensure that an individual experiences a normalized psychological development. The eight stages, given that Pamela is over 65 in age, she belongs to Ego Integrity vs. Despair.

In terms of physical development, there is increased vulnerability to diseases, and this led to the patient experiencing many illnesses such as chest pain and aching joints all over. The elderly normally experience changes such as integumentary including sagging, wrinkling; musculoskeletal changes including loss of elasticity in the joints; metabolic rate declines and other changes that normally reduce the pride and ego of the elderly. Therefore, they sometimes feel disadvantaged by their age.

The patient had retired long ago and therefore has the challenge of feeling despair, as he lived in a room alone, with the physical challenges she could move around as she used to when she was young. There is reduced income for the client as she had retired. Lastly Pamela has lived for; long and therefore have gone through sad period when the family members dies and live her still alive.

Cultural Considerations

The patient is an American belonging to the Caucasian ethnic group. She has lived in the United States whole her life without any histories of migration to other countries. She resides in New York and fluent English speaker. She loves to watch movies and listen to some old school music in order to avoid having more heart attacks due to her status. She is a retired nurse, with low-income sources and depends on the government for social security and Medicare, and a Christian who does not have a lot of cultural consideration and therefore, gives an easy time to the healthcare professionals.

Psychosocial Considerations

Pamela understands her situation but the best thing is that she lives with one of her daughters to help her go through the experiences. However, the patient is a very active personality; this is despite the fact that she has the arthritic symptoms. She acknowledges and already accepts the heart attack she normally have, but sometimes this makes her very anxious as she keeps on wondering the moment it will strike her again.

Physical Assessment

Due to her combination of chest pains and the heart attacks, I would critically assess her heart functioning and the lungs too. There should be a careful monitoring of the increasing chest pains and heart attack, this may be a proof of myocardial infarction and therefore should be admitted for more checkups. The patient’s cholesterol should also be monitored and therefore should be advised to have enough physical exercises but light ones, to ensure free-flowing blood circulation. Some medications such as HMG Co-reductase should be administered to reduce the cholesterol level in the body.

Need Priorities for the Patient

There are many elderly person in the world who are faced with such challenges of heart attack and have chest pain as they continue to grow older. To prioritize the needs, there should be assessment and screenings of the heart functions of these persons, and some education that is related to the hypertension in old age and how they can go through the matter. The only difficult part here is the news that some types of food that they will have to avoid, such as the fatty foods. They should be eating mostly vegetables with reduced sugary contents and some exercises.

Collaborative Recourses

The first collaborative resource for the patient would be church, where she could meet other friends and family and feel loved and cared for. Therefore, she will not have to feel lonely in the house and alone too. The next resource is the family members like her daughter and grandchildren coming over to give her a visit at the home. Doing some, exercises can be another resource helping her to increase the heart beat and circulation of blood.


The interview took place in the room of the interviewee, I ensured that her daughter was not around so that we could have free environment for her to disclose everything to me. I first assured her of confidence with the information and that it would help to improve the healthcare of the elderly as she is. The tension between us reduced the more I was asking questions, therefore we could communicate freely.

During my time with Pamela, it helped learn how important health assessment was to the patients, mostly to the delicate elderly, who usually feel exclude in most societies. I learned the health risks that the elderly go through and can now have recommendations on how to solve their problems. Some of the barriers I had were the problem of lack of confidence with the information, in a way the interviewee at times did not provide all the information relevant for this assessment. However, the more question she developed the confidence and was able to open up.


Agedcare. (2013, October).

Comprehensive health assessment of the Older Person

. Retrieved from Department of Health:


. (2000). Retrieved from Encyclopedia of Surgery:

D’Amico, D. a. (2011). Cilinical Pocket Guide for Health an Physical Assessment .

Nursing Author Donita D’Amico

, 36-38.

Hoffman. (2001, January).



Wilson, D. (1990).

Hematemesis, Melena, and Hematochezia

. Retrieved from NCBI: