The purpose of this kind of paper is usually to discuss the results of any comprehensive overall health assessment on a patient of my deciding on. This complete assessment included the person’s complete well being history and a head-to-toe physical examination. The complete health history information was obtained by simply interviewing the person, who was thought to be a reliable origin. Other sources of information, such as medical records, were not available at time of the interview. Physical assessment data was obtained through inspection, palpation, percussion, and auscultation techniques.
The case examine results are interpreted from the perspective of a rn, and 3 nursing diagnoses are determined.
Biographic Info
M. H. is a 63-year-old married white colored female. She is currently jobless for four months. Her most recent job of eight years was as a personal home health aid for any friend’s seniors parents with since passed away. She was created in Zoysia grass, New York to a family of German born decent. Your woman currently lives in a region of Buffalo, N.
Con.
English can be her major language.
Traditions and Spirituality
M. They would. was raised within a traditional German born family exactly where her dad was the head of the household. However , her father and mother built many decisions mutually and shared household chores (Purnell, 2014). Her father was an Usaf pilot during World War II, and then worked as being a chemical professional until pension. The household atmosphere was caring and well intentioned. She and her five siblings had been brought up as Roman Catholics. They were expected to be courteous, use table manners, end up being on-time to meals, value their parents, do because they were informed, share, end their chores before re-creating, get good grades at school, pray ahead of meals and at bedtime, and attend church every On the and on ay days (Purnell, 2014)
Past Health Background
When she was a child, M. They would. did not possess any serious illness, nor really does she include any serious illnesses at the moment. She did, however , have got a severe case of chickenpox once she was about 3-years-old, and shingles about 18 years back. M. L. has not been in different major incidents or got any deadly injuries during her existence. She has recently been hospitalized two times for childbirth. Her obstetric history contains Gravida 2/Term 2/Preterm 0/Abortion 0/Living 2 . Both births were simple vaginal deliveries.
Surgical history includes tubal ligation at age 24, and removal of not cancerous cysts in her breast on the left, left quarter, and left wrist between your years 1998-2003. All of her childhood vaccinations are current. She gets vaccinated pertaining to influenza nearly every year, nevertheless she would not get vaccinated this season. The girl received the varicella zoster virus vaccine in February, 2015; no reactions known. Her last tetanus taken was even more 10 than years ago. Your woman denies ever before having been confronted with tuberculosis (TB), and nor has your woman ever had a TB skin area test (Jarvis, 2012).
Meters. H. recognizes her principal physician each year for a physical. Her last physical was in February, 2014. She also perceives her dental office annually for the check-up and cleaning. She’s currently planned for The spring, 2015. Since a child she never needed further lenses, nevertheless for the last 15 years this lady has needed spectacles for studying. Therefore , her vision is usually checked yearly, most recent visit having been in January, 2015. Because this lady has a history of benign cysts in her breast tissue, your woman gets a mammogram every single five years. Her previous mammogram was at 2010. Effects of her Pap assessments have never recently been abnormal. Your woman cannot remember the day of her last gynecological exam. In addition, she gets a coloscopy every couple of years, as her daddy died of colon cancer.
In relation to allergy symptoms, M. L. has no noted drug allergy symptoms. Current over-the-counter medications contain an occasional 400-600 mg dose of ibuprofen for “aches and pains, a daily supplement, and melatonin for sleeplessness, and antacids, such as Tums, for her “heartburn. Her current prescription medications incorporate a 225 magnesium tablet of Venlafaxine HCL oncedaily to get anxiety related dizziness, and a 20 mg tablet of Atorvastatin for heart problems. She refreshments alcohol socially, approximately two 12 ounces beers a day. She is an ex smoker of one pack of cigarettes a day for nearly forty years. Her quite day was Sept. 2010, 2011. She denies the usage of street medicines.
Review of Devices
M. They would. states that she is generally in good overall health. Zero cardiac, breathing, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or perhaps gastrointestinal complications. No great skin disease. Skin area is green, dry, and void of bumps, rashes, or perhaps lesions. Zero recent hairloss; head is definitely normocephalic. Students equally reactive to light; no history of glaucoma or perhaps cataracts. Ear are in normal alignment; no good chronic attacks, hearing loss, tinnitus, or release. Nose and sinus record includes obvious nasal release “since last October, and occasional nasal area bleeds; declares she use for get nasal area bleeds frequently a child. Throat and mouth are missing of lesions; no blood loss gums, sore throat, dysphagia, hoarseness, or changed taste. Neck is void of pain, inflammation, tender nodes, and goiter; full range of motion.
M. H. states that the lady performs home breast exams routinely and denies any lumps or perhaps discharge. Lung area are clear; peripheral pulses present bilaterally; capillary refill less than a few seconds. Heart rate is in normal sinus. Bowel sounds can be found in all quadrants. Her psychological status is appropriate. M. L. denies recent weight change, weakness, fever, sweats, or fatigue (Jarvis, 2012). Unusual findings incorporate an elevated cholesterol level, which is also familial. Furthermore, she has a history of linked to stress anxiety, and was clinically determined to have anxiety related dizziness this year. She declares that just before she started out taking a medicine her doctor prescribed, her dizzy means could happen whenever you want. As a result, she avoids selected situations, including riding in a boat.
Functional Examination
After away from Bryant and Stratton business school in her early on twenties, Meters. H. put in 15 years as a supervisor of a number of apartment things. She after that worked like a manager of a retail mini-mart for the next 15 years until she acquired layed-off. Meanwhile, with the help of her siblings, the girl was taking care of her older mother, her mother’s hubby, and aged mother-in-law right up until they all died. Shortly after these types of events, close friends hired her to care for their parents, and now they may have passed away. However , she still helps the friends by cleaning their house, completing simple do-it-yourself tasks, and going grocery shopping and jogging errands on their behalf.
M. L. lives with her spouse of 42 years. Your woman was raised Both roman Catholic, features God, nevertheless does not go to church on a regular basis. She declares that she is an honest, hard-working woman. The girl takes her dog for any walk a couple of times a day to get exercise, and is also independent in her actions of daily living. She and her hubby enjoy time with family and friends, and number dinners and get-togethers typically. Her hobbies include sewing, upholstery, and gardening. Receiving 6-8 hours sleep through the night is Meters. H. is actually normal routine, although she gets occasional stress-related insomnia.
The girl states your woman tries to take in healthy, is aware of “good vs . “bad foodstuff choices, and does not have virtually any food intolerances. Equally her spouse and she share the cooking and grocery shopping duties (Jarvis, 2014). A typical daily diet includes a normal size bowl of whole grain cereal with skim dairy or a proteins shake breakfast every day, soup and/or sandwich to get lunch, and a lower of lean with a veggie side for lunch. She and her spouse occasionally order pizza, have a fish smolder on Fridays during loaned, or go out for Oriental food. Normal elimination pattern includes one or two bowel moves a day; this lady has no problems urinating, even though if the lady drinks regular coffee, it will eventually cause urinary frequency.
In terms of interpersonal relationships, she has an extremely strong relationship with her siblings and their families, her husband’s relatives, and her children and their families. Your woman enjoys tending to her grandchildren on an “as needed basis. She meets your criteria time spent alone since productive and/or relaxing, proclaiming “everyone has to have a little time alone to work with their own projects (Jarvis, 2014). She views her area, house, and work environment safe. She claims she has the “typical strains of life, like earning profits to settle payments, repairing their very own old house, and becoming married andhaving a family.
Conclusion
Depending on the outcomes of the complete assessment info, M. L. is a relatively healthy person, who has not had any serious or life-threatening medical problems during her lifestyle. She reveals with stress and stress related dizziness that is at present under control with medication. Your woman follows plan her doctor and other healthcare professions on a regular basis, eats healthful, and usually takes her prescription drugs as approved. She also provides a healthy psychological status with family and friends.
Via a medical perspective, 3 nursing diagnoses apply to Meters. H. in her current situation. The first priority diagnosis is Anxiety (moderate) related to pressure as described by sleeping disorders and fatigue. Second top priority diagnosis is deficient Know-how related to stress and fatigue as described by Meters. H. stating lack of full understanding of the disorder. The third priority diagnosis is usually disturbed Sensory Perception (kinesthetic) related to psychological stress as manifested by simply sensory effects (i. e., dizziness). These types of diagnoses can assist nurses to recognize appropriate affluence that will help M. H. accomplish an optimum state of wellness (Doenges, Moorhouse, & Murr, 2010).
References
- Doenges, M. E., Moorhouse, M. Farreneheit., & Murr, A. C. (2010). Nurse’s pocket guidebook: Diagnoses, Prioritized Interventions, and Rationales (12th ed. ). Philadelphia, PA: F. A. Davis Organization.
- Jarvis, C. (2012). Physical Examination and Health Analysis (6th male impotence. ). St . Louis, MO: Elsevier.
- Purnell, L. G. (2014). Broadly Competent Healthcare (3rd male impotence. ). Phila., PA: F. A. Davis Company.
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