Week 5 RUA health history PDF

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RUA HEALTH HISTORY ON A PATIENT OF YOUR CHOICE...

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Week 5: RUA: Health History Desiree Contes Chamberlain University School of Nursing NR302 – Yang – Health Assessment 1 October 2021

Health History Assessment I chose to do a health assessment on a family friend, and I will use the initials CJ. CJ allowed me to do this assessment and was able to sit down with me for thirty minutes to complete this assessment. I explained to my patient the full assessment and explained everything step by step. We were able to do the full assessment with no interruptions. Demographic Data CJ is a 63-year-old female who is of a Hispanic background and owns her own home and was happy when she finally was able to buy her own home. She lives with her husband, daughter, son, and her grandson. CJ’s primary language spoken is Spanish and she is from Honduras and speaks only a little of English as she was able to learn some English from her children who can speak it very well. My patient was alert throughout the full assessment and was very happy going and was very much excited to be my patient and do this assessment with me. Perception of Health CJ keeps herself in a good health standard with eating healthy foods and getting in a regular daily exercise and she enjoys trying out new daily work outs that will enhance her continuous work out history. She has a good idea of her healthy status and why she wants to maintain a healthy lifestyle. She likes to maintain a vegetarian diet and she exercise’s five days a week. She sates that she also likes when her children join in with her daily work out routines. Past Medical History CJ has no past medical history. She is content with her health and is always looking to make healthy meals daily for her and her family. She has always known if there was going to be an issue with her health it would be due to neglecting her health and that was something that she

refused to do. She likes the fact that she is healthy and maintains an active lifestyle with her family. Family Medical History CJ’s father has a history of CHF, diabetes mellitus type 2, hypertension and is also a dialysis patient in which is the reason for her wanting to maintain a healthy life. CJ’s mother has a history of hypertension and diabetes and soon after started to change her diet to decrease the number of medications she would have to take. For CJ knowing that her parents both suffered from diabetes, she did not want to later start to suffer from that disease, so she continued with her healthy lifestyle. Review of Systems CJ’s health in general is a patient with no health issues, is current at a healthy standpoint. Her skin color is normal with a pinkish color and is very much appropriate to her ethnicity, and she is warm at touch, which is also normal for her. CJ has no lesions and as I was checking her head, I did not notice any infestation, which was a good sign. Her nail beds are pink, and the shape is round conveyed at 160 degrees and has a capillary refill of 2 seconds. I did not notice any signs of edema. There is no sign of distress, and her mood was comfortable, and her speech was clear and did not have any problems with answering any questions that I asked her. She was awake, alert, and orientated times four to person, place, time, and situation. There are no discharge or redness in her eyes and her pupils are round and reactive to light. There is no discharge, swelling or redness in her ears and I did my assessment. CJ passed the whisper test and there is no deformity or inflammation in her nose. There is no bilateral patency noted and no drainage. Lips are pink and moist, and the patient appears well, and she stated that she always used lotion to keep her skin from becoming dry.

Development Considerations CJ was a Nurse for more than thirty years and has been happily married for the past twenty years. She has two kids and one grandchild, who currently live with her. She is content with her life and is happy as they keep a tight nit bonded family who enjoy doing things together. The always had conversations regarding maintaining a healthy life and making sure to consume a lot of healthy foods. Cultural Consideration Patient is Spanish speaking with a low amount of English spoken. As a nurse we should take a little more time when doing a health assessment on a patient with a language barrier as to make sure that all parts of the assessment is done and understood. It should help to work with an interpreter or a family member who knows English very well to ensure that the patient is fully aware and understands what is being said and is able to ask questions if there are any questions the patient may want to ask. It does help when the nurse and patient speak to same language, but we know that it is not always the case and help would be greatly appreciated. Psychosocial Considerations CJ is a 63-year-old female with no history of psychosocial considerations and there was never a problem with this. CJ also states that she did not have any family history of psychosocial considerations and that her family also spoke to each other if any concerns where to come about. Her family was small but also big at heart and were always together to help each other out and always wanting to stay uplifted. Collaborative Recourses The patients’ children were in her life actively helping her around the house if needed and going out to do food shopping for her to buy minor things that she may need to cook and get

things done around the house. They were also helpful to her if she needed a ride to her doctor’s appointment or if she just wanted to have someone to accompany her. She goes to church every Sunday with her husband and sometimes her children would come along. CJ’s family would also go out for dinner or a movie to be able to spend out door quality time that she feels every family should do. Reflection This assessment helped me practice some of the skills that I have learned in my health assessment class and lab. I was able to ask my patient questions about her past and present medical history as well as her family history and there was no reason for me to use an interpreter because I was able to communicate with her being that we spoke to same language which is both helpful Spanish is my second language, and I can speak it fluently and effectively. This assessment was helpful because I will become a nurse once I graduate and complete the required degree curriculum and being able to do this health assessment on a patient allowed me to see what I will be doing with every patient I will assess. It also gave me the opportunity to connect with the patient and understand her background and would give me the opportunity to compare on something that may be a difference or a change. So, when I must do more assessments on other patients, I would be more comfortable and would ask all the necessary questions that are needed to be asked. This experience was valuable and helpful.

Reference: Hubert, R.J., & VanMeter, K. (2018). Gould’s pathophysiology for the health professions. St. Louis, MO: Elsevier Facione, P. A., & Gittens, C.A. (2016). Think Critically. (3rd ed.). Boston: Pearson....