Comprehensive Health Assessment Paper
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The intent of this paper is to discourse the consequences of a comprehensive wellness appraisal on a patient of my choosing. This comprehensive appraisal included the patient’s complete wellness history and a head-to-toe physical scrutiny. The complete wellness history information was obtained by questioning the patient. who was considered to be a dependable beginning. Other beginnings of informations. such as medical records. were non available at the clip of the interview. Physical scrutiny informations was obtained through review. tactual exploration. percussion. and auscultation techniques. The instance survey consequences are interpreted from the position of a registered nurse. and three nursing diagnosings are identified.
M. H. is a 63-year-old married white female. She is presently unemployed for four months. Her most recent employment of seven old ages was as a private place wellness assistance for a friend’s aged parents who have since passed off. She was born in Buffalo. New York into a household of German decent. She presently lives in a suburb of Buffalo. N. Y. English is her primary linguistic communication.
Culture and Spiritualty
M. H. was raised in a traditional German household where her male parent was the caput of the family. However. her male parent and female parent made many determinations reciprocally and shared family jobs ( Purnell. 2014 ) . Her male parent was an Air Force pilot during World War II. and so worked as a chemical applied scientist until retirement. The family ambiance was loving and respectful. She and her five siblings were brought up as Roman Catholics. They were expected to be polite. usage table manners. be on-time to repasts. esteem their seniors. do as they were told. portion. complete their jobs before animating. acquire good classs in school. pray before repasts and at bedtime. and attend church every Sunday and on holy yearss ( Purnell. 2014 )
. Past Health History
When she was a kid. M. H. did non hold any serious unwellness. nor does she hold any chronic unwellnesss presently. She did. nevertheless. have a terrible instance of varicella when she was about 3-years-old. and shingles about 18 old ages ago. M. H. has non been in any major accidents or had any dangerous hurts during her life. She has been hospitalized two times for childbearing. Her obstetric history includes Gravida 2/Term 2/Preterm 0/Abortion 0/Living 2. Both births were unsophisticated vaginal bringings.
Surgical history includes tubal ligation at age 24. and remotion of benign cysts in her left chest. left cheek. and left carpus between the old ages 1998-2003. All of her childhood inoculations are up to day of the month. She gets vaccinated for grippe about every twelvemonth. but she did non acquire vaccinated this season. She received the chickenpox shingles virus vaccinum in February. 2015 ; no reactions noted. Her last lockjaw shooting was more 10 old ages ago. She denies of all time holding been exposed to TB ( TB ) . and nor has she of all time had a TB tegument trial ( Jarvis. 2012 ) .
M. H. sees her primary doctor every twelvemonth for a physical. Her last physical was in February. 2014. She besides sees her tooth doctor yearly for a check-up and cleansing. She is presently scheduled for April. 2015. As a kid she ne’er needed disciplinary lenses. but for the last 15 old ages she has needed spectacless for reading. Therefore. her vision is checked yearly. most recent assignment holding been in January. 2015. Because she has a history of benign cysts in her chest tissue. she gets a mammogram every five old ages. Her last mammogram was in 2010. Consequences of her Pap trials have ne’er been unnatural. She can non remember the day of the month of her last gynaecological test. She besides gets a coloscopy every twosome of old ages. since her male parent died of colon malignant neoplastic disease.
In relation to allergic reactions. M. H. has no known drug allergic reactions. Current nonprescription medicines include an occasional 400-600 milligram dosage of isobutylphenyl propionic acid for “aches and pains” . a day-to-day vitamin. and melatonin for insomnia. and alkalizers. such as Tums. for her “heartburn” . Her current prescription medicines include a 225 mg tablet of Venlafaxine HCL one time daily for anxiousness related giddiness. and a 20 mg tablet of Atorvastatin for high cholesterin. She drinks intoxicant socially. about two 12 ounce beers a twenty-four hours. She is a former tobacco user of one battalion of coffin nails a twenty-four hours for about 40 old ages. Her quite day of the month was September. 2011. She denies the usage of street drugs.
Review of Systems
M. H. states that she is by and large in good overall wellness. No cardiac. respiratory. hormone. vascular. musculoskeletal. urinary. hematologic. neurologic. GU. or GI jobs. No history of skin disease. Skin is pink. dry. and nothingness of contusing. roseolas. or lesions. No recent hair loss ; caput is normocephalic. Pupils every bit reactive to visible radiation ; no history of glaucoma or cataracts. Ears are in normal alliance ; no history of chronic infections. hearing loss. tinnitus. or discharge. Nose and sinus history includes clear nasal discharge “since last October” . and occasional nose bleeds ; states she usage to acquire nose bleeds frequently as a kid. Mouth and pharynx are absent of lesions ; no hemorrhage gums. sore pharynx. dysphagia. gruffness. or altered gustatory sensation. Neck is nothingness of hurting. swelling. stamp nodes. and goitre ; full scope of gesture.
M. H. states that she performs self chest tests routinely and denies any balls or discharge. Lungs are clear ; peripheral pulsations present bilaterally ; capillary refill less than 3 seconds. Heart rate is in normal fistula. Bowel sounds are present in all quarter-circles. Her psychosocial position is appropriate. M. H. denies recent weight alteration. failing. febrility. workout suits. or weariness ( Jarvis. 2012 ) . Abnormal findings include an elevated cholesterin degree. which is besides familial. Furthermore. she has a history of emphasis related anxiousness. and was diagnosed with anxiousness related giddiness in 2012. She states that before she started taking a medicine her physician prescribed. her dizzy enchantments could go on at any clip. As a consequence. she avoids certain state of affairss. such as siting in a boat.
After graduating from Bryant and Stratton concern school in her early mid-twentiess. M. H. spent 15 old ages as a director of several flat composites. She so worked as a director of a retail mini-mart for the following 15 old ages until she got layed-off. Meanwhile. with the aid of her siblings. she was taking attention of her aged female parent. her mother’s hubby. and aged mother-in-law until they all passed off. Shortly after these events. friends hired her to care for their parents. and now they have passed off. However. she still helps the friends by cleaning their house. finishing simple place betterment undertakings. and traveling food market shopping and ruuning errands for them.
M. H. lives with her hubby of 42 old ages. She was raised Roman Catholic. believes in God. but does non go to church on a regular basis. She states that she is an honest. hard-working adult female. She takes her Canis familiaris for a walk several times a twenty-four hours for exercising. and is independent in her activities of day-to-day life. She and her hubby enjoy clip with household and friends. and host dinners and get-togethers frequently. Her avocations include run uping. upholstery. and horticulture. Geting 6-8 hours sleep at dark is M. H. ’s normal form. although she has occasional stress-related insomnia.
She states she tries to eat healthy. is cognizant of “good” versus “bad” nutrient picks. and does non hold any nutrient intolerances. Both her hubby and she portion the cookery and food market shopping responsibilities ( Jarvis. 2014 ) . A typical day-to-day diet includes a little bowl of whole grain cereal with skim milk or a protein shingle for breakfast. soup and/or sandwich for tiffin. and a cut of thin meat with a vegetable side for dinner. She and her hubby on occasion order pizza. acquire a fish Fry on Fridays during Lent. or travel out for Chinese nutrient. Normal riddance form includes one or two intestine motions a twenty-four hours ; she has no jobs urinating. although if she drinks regular java. it will do urinary frequence.
In respects to interpersonal relationships. she has a really strong relationship with her siblings and their households. her husband’s household. and her kids and their households. She enjoys caring for her grandchildren on an “as needed” footing. She qualifies clip exhausted entirely as productive and/or relaxing. saying “everyone needs a small clip entirely to work on their ain projects” ( Jarvis. 2014 ) . She considers her vicinity. house. and work environment safe. She states she has the “typical emphasiss of life. like doing money to pay measures. mending their old house. and being married and holding a family” .
Based on the consequences of the comprehensive appraisal informations. M. H. is a comparatively healthy individual. who has non had any serious or dangerous medical jobs during her life. She presents with anxiousness and anxiousness related giddiness that is presently under control with medicine. She follows up with her doctor and other wellness attention professions on a regular footing. eats healthy. and takes her medicines as prescribed. She besides has a healthy psychosocial position with household and friends.
From a nursing position. three nursing diagnosings apply to M. H. in her current state of affairs. The first precedence diagnosing is Anxiety ( moderate ) related to emphasize as manifested by insomnia and giddiness. Second precedence diagnosing is lacking Knowledge related to anxiousness and giddiness as manifested by M. H. saying deficiency of complete apprehension of the status. The 3rd precedence diagnosing is disturbed Centripetal Perception ( kinaesthetic ) related to psychological emphasis as manifested by centripetal deformations ( i. e. . giddiness ) . These diagnosings will help nurses to place appropriate intercessions that will assist M. H. achieve an optimum province of health ( Doenges. Moorhouse. & A ; Murr. 2010 ) .
Doenges. M. E. . Moorhouse. M. F. . & A ; Murr. A. C. ( 2010 ) . Nurse’s pocket usher: Diagnosiss. Prioritized Interventions. and Rationales ( 12th ed. ) . Philadelphia. Dad: F. A. Davis Company. Jarvis. C. ( 2012 ) . Physical Examination and Health Assessment ( 6th ed. ) . St. Louis. Moment: Elsevier. Purnell. L. D. ( 2014 ) . Culturally Competent Health Care ( 3rd ed. ) . Philadelphia. Dad: F. A. Davis Company.