Health History Assessment Essay

Health History Assessment Essay

Health History Assessment Essay

Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool.

Review this week’s Learning Resources as well as the Taking a Health History media program in Week 3, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment.Health History Assessment Essay

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Specific health assessment refers to an assessment of a specific problem and it may be the initial assessment or an ongoing assessment (Bayoumi., 2009). A risk assessment is a type of assessment that uses an individual ‘s personal data, genetic and environmental information to determine the risk of developing a specific disease such as cervical cancer, breast cancer, pancreatic cancer etc. (Duke, 2010). The objective of this essay is to discuss about a type of specific assessment which is pain assessment. In order to answer this question, first of all, the essay will touch on the differences between comprehensive health assessment and specific assessment. Later, the essay will discuss on the purpose and intent of pain assessment, how this pain assessment contributes to a person’s comprehensive health assessment and three abnormal findings when performing the pain assessment. Lastly, it will discuss the actions that I can take for each of the three abnormal findings.Health History Assessment Essay

Body
A comprehensive health assessment is a thorough head-to-toe physical examination which includes a review of the medical history , a complete physical examination , a complete laboratory tests, body fat assessment, exercise tolerance test, nutrition assessment, fitness assessment and stress management. (Glymph, 2010). It is usually the initial assessment. On the other hand, a specific assessment is problem oriented . It focuses on a specific problem and not a general health (Bayoumi., 2009). If a patient’s condition does not permit a comprehensive health assessment, a specific assessment of the patient’s current health problem is done. It is done frequently to monitor and evaluate the patient’s progress (Bayoumi., 2009). A specific assessment is a part of a comprehensive health assessment. When the patient’s condition is favorable again, a comprehensive health assessment is carried out. For example, one day, a 65-year-old man came to the emergency department with acute chest pain. Instead of performing a comprehensive health assessment, I have to perform a specific pain assessment for this patient since his condition is not favorable. I should focus on chest pain assessment, perform an electrocardiography test and laboratory tests like complete blood count, biochemistry test, creatinine kinase test and test for troponin (Fogoros, 2009). Comprehensive health assessment is not suitable in this situation as it will provide less accurate information. It should be done when the patient’s condition has gotten better . Among the tests for a comprehensive health assessment are urine analysis, chest x-ray, abdominal ultrasound, fitness test, ankle brachial index, visual acuity test etc (Billinkoff, 2012).Health History Assessment Essay

According to the Australian and New Zealand College of Anaesthetists, pain assessment has been identified as the 5th vital signs when assessing a patient (Wood, 2008). Pain assessment is important in providing an effective management. Pain assessment involves factors that may influence patient’s experience and expression of pain, the process of describing pain, and factors that may affect nurses in pain assessment such as inadequate knowledge or skills about pain, patient’s poor attitude, patient’s age, type and stage of disease and misconceptions about pain like the fear that patients will be addicted to pain medication (Wood, 2008). Pain assessment can be carried out using an assessment tool that identifies the quantity and quality of the patient’s experience of pain (Wood, 2008). A pain scale from 0-10 where 10 represents worst possible pain can be used.

The first abnormal finding when I perform a pain assessment in a 55-year-old man is an acute chest pain. Generally, acute chest pain is an emergency situation as it can be life-threatening. Acute chest pain is a warning symptom for heart attack, angina pectoris, aortic dissection, pulmonary embolism, spontaneous pneumothorax , perforated viscus, pericarditis, pneumonia and other esophagus related causes (Cunha & Stoppler, 2012). As a professional nurse, first of all, I should assess the patient’s airway, breathing and circulation (Lynda, 2009). This is the primary assessment. Secondary assessment includes location of pain, the nature of pain, characteristics of pain, chronology of pain, the situation at the time of pain, provoking and relieving factors and other symptoms in association with chest pain (Lynda, 2009). In this patient, his airway and circulation are clear but he has shortness of breath. The pain started substernally after exercising and radiates to the jaw, left arm , back and neck. The pain is dull in character. The pain is continuous and constant. It lasts for more than 30 minutes and is not relieved by rest. According to the patient, he rates the pain as 8/10 according to the pain scale. For interventions, I should have the patient rests on the bed in Fowler or Semi-Fowler position (Nanda, 2009). Health History Assessment Essay Later, I will perform 12 leads electrocardiography to rule out the causes of the patient’s chest pain (Nanda, 2009). Also, I will observe his 5 vital signs such as body temperature, blood pressure, pulse, respiratory rate and pain (Nanda, 2009). If necessary, I will give patient oxygen or pain killer to relieve pain. At the same time, I will observe the side effects of the medications. Besides, I will set up an intravenous drip to rehydrate patient and take blood samples for further laboratory investigations. It is necessary for me to try and reduce environmental stimuli such as noises and be calm when dealing with this patient. I should continuously monitor the patient’s vital signs and look out for any complication if there is any (Nanda, 2009).

Secondly, the patient has headache. As a professional nurse, I should start my assessment from collecting subjective data from the patient. Subjective data that I should collect are like trying to understand the causes of the headache, aware of trigger factors, measures to reduce headache, location, frequency and pattern of pain, beginning of the attack, accompanying symptoms and family history (Nanda, Nursing Assessment and Nursing Diagnosis of Headaches , 2012). The objective data include the patient’s behavior like anxious, changes in ability to perform daily activities and body temperature (Nanda, Nursing Assessment and Nursing Diagnosis of Headaches , 2012) . It is found that the patient is constantly stressed out. He always takes one or two tablets of paracetamol when he has a headache. Often, the headache is located frontally but sometimes it involves the whole head. The pain is throbbing, moderate intensity, lasts about 4 hours each time and has 2-4 attacks each month. He had the first attack 10 years ago. Migraine headache runs in his family. Objective examination shows that the patient is anxious and is not able to perform his daily activities when he has an attack. The patient also experiences fatigue and has loss of appetite too in association with migraine headache. The interventions that can be taken for this patient include ensure that the patient takes medication when he has migraine attack, advise the patient to make a record of the attack, discuss the physiological dynamics of stress and anxiety with the patient, instruct the patient to acknowledge me when the pain is severe, place patient in a dark and quiet room, put a cold compress on his head, massage his head if necessary, employ techniques of therapeutic touch and stress reduction, observe for any complications and give icy drinks containing carbonate to the patient (Nanda, Headache Nursing Care Plan Interventions, 2012).Health History Assessment Essay

Also, during the pain assessment, it is found that the patient experiences pain during urination. To assess the patient, subjective data that need to be collected are asking the patient whether he experiences pain during urination, frequency of urination, color of urine, the amount of urine each time, the presence or absence of odor, presence or absence of pain in the abdomen and other associated symptoms (Johny, 2011). Objective data include the vital signs of the patient such as the temperature, pulse, respiratory rate, blood pressure and urine output and presence or absence of abdominal muscle guarding (Johny, 2011). A urine analysis should be carried out. If necessary, an abdominal x-ray should be scheduled. It is found that the patient has moderate pain during urination, urinate 3 times per hour, yellow colour urine, small amount of urine each time, presence of foul smell and pain is felt at the back. Patient experiences fever and malaise as well. His vital signs are normal and there is no abdominal muscle guarding. Urine analysis shows that the patient has pyelonephritis. As a professional nurse, I should constantly monitor his urine output, monitor the results of repeated urine analysis, record the location,duration and intensity of pain, provide comfort measures such as massage, encourage the used of focused relaxation breathing, provide perianal care as well as give antibiotics and analgesics according to the doctor’s order (Wiwik, 2009).Health History Assessment Essay

Conclusion
In conclusion, a comprehensive health assessment involves an assessment from head-to-toe while a specific assessment is problem oriented. The specific assessment is carried out when the patient’s condition is not favourable for a comprehensive health assessment. During the pain assessment in a 55-year-old patient, I found that he has an acute chest pain, migraine headache and pain during urination. As a professional nurse, I should carry out subjective assessment, objective assessment and laboratory tests for each abnormal findings. There is a specific care plan for each abnormal finding with the main objective which is to provide comfort to the patient and to reduce the pain.

Identifying Data & Reliability
Tina arrived today complaining about a wound on
her right foot. The wound is 2cm x 1.5cm with a
depth of 2.5mm. The patient is experiencing pain
as a result of the fall and wound. She is taking
advil for pain with minium effectiveness. Instructed
patient to take medication every 6 to 8 hours as
needed for pain. Patient also presented with a
fever, a high blood glucose and elevate blood
cover. Patient has a family history of high blood
pressure. Culture taken of wound and sent to lab.
Eduated patient on importance of maintaing a safe
blood sugar.Health History Assessment Essay
Ms. Jones is a pleasant, 28-year-old obese African
American single woman who presents to establish
care and with a recent right foot injury. She is the
primary source of the history. Ms. Jones offers
information freely and without contradiction.
Speech is clear and coherent. She maintains eye
contact throughout the interview.
General Survey
Patient is in school and has been understress
while in school. Patient not concentrating on
health due to stress. Educated patient on the
importance of stress relief. Patiet is not currntly in
a relationshiop and lives with family. Pt has a
history of asthma which is currently mild with
albuterol use a couple of times a week.
Ms. Jones is alert and oriented, seated upright on
the examination table, and is in no apparent
distress. She is well-nourished, well-developed,
and dressed appropriately with good hygiene.
Chief Complaint
The patient’s chief complaint is an infected wound
on the right foot due to a fall. This is a followup
visit from the ER.

“I got this scrape on my foot a while ago, and I
thought it would heal up on its own, but now it’s
looking pretty nasty. And the pain is killing me!”
History Of Present Illness
Patient fell and visited the ER where the wound
was cleaned and she was given pain medication.
She is in pain currently and stated that she is
unable to use it to move independently.
Ms. Jones reports that a week ago she tripped
while walking on concrete stairs outside, twisting
her right ankle and scraping the ball of her foot.
She sought care in a local emergency department
where she had x-rays that were negative; she was
treated with tramadol for pain. She has been
cleansing the site twice a day. She has been
applying antibiotic ointment and a bandage. She
reports that ankle swelling and pain have resolved
but that the bottom of the foot is increasingly
painful. The pain is described as “throbbing” and
“sharp” with weight bearing. She states her ankle
“ached” but is resolved. Pain is rated 7 out of 10
after a recent dose of tramadol. Pain is rated 9
with weight bearing. She reports that over the past
two days the ball of the foot has become swollen
and increasingly red; yesterday she noted
discharge oozing from the wound. She denies any
odor from the wound. Her shoes feel tight. She
has been wearing slip-ons. She reports fever of
102 last night. She denies recent illness. Reports a
10-pound, unintentional weight loss over the
month and increased appetite. Denies change in
diet or level of activity.
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Medications
Patient has an inhaler which she uses multiple
times in a week. Patient is also taking tramadol as
needed for pain in addition to Avidl or tylenol.
Patient was prescribed medication for diabetes
but is currently not taking the medication.
Educated patitent on blood sugar control.
Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID prn (menstrual
cramps) • Tramadol 50 mg PO BID prn (foot pain) •
Albuterol 90 mcg/spray MDI 2 puffs Q4H prn
(Wheezing: “when around cats,” last use three
days ago)
Allergies
Patient is allergic to cats and penicillin
Penicillin: rash • Denies food and latex allergies •
Allergic to cats and dust. When she is exposed to
allergens she states that she has runny nose, itchy
and swollen eyes, and increased asthma
symptoms.
Medical History
Patient has a history of diabetes and asthma. Has
family history of high blood pressure which she
presented with today in the office.
Asthma diagnosed at age 2 1/2. She uses her
albuterol inhaler when she is around cats and
dust. She uses her inhaler 2 to 3 times per week.
She was exposed to cats three days ago and had
to use her inhaler once with positive relief of
symptoms. She was last hospitalized for asthma
“in high school”. Never intubated. Type 2 diabetes,
diagnosed at age 24. She previously took
metformin, but she stopped three years ago,
stating that the pills made her gassy and “it was
overwhelming, taking pills and checking my
sugar.” She doesn’t monitor her blood sugar. Last
blood glucose was elevated last week in the
emergency room. No surgeries. OB/GYN:
Menarche, age 11. First sexual encounter at age
18, sex with men, identifies as heterosexual. Never
pregnant. Last menstrual period 3 weeks ago. For
the past year cycles irregular (every 4-8 weeks)
with heavy bleeding lasting 9-10 days. No current
partner. Used oral contraceptives in the past.
When sexually active, reports she did not use
condoms. Never tested for HIV/AIDS. No history
of STIs or STI symptoms. Last tested for STIs four
years ago. Hematologic: Denies bleeding,
bruising, blood transfusions and history of blood
clots. Skin: Reports acne since puberty and
bumps on the back of her arms when her skin is
dry. Complains of darkened skin on her neck and
increase facial and body hair. She reports a few
moles but no other hair or nail changes.
Health Maintenance
Patient is finding it difficult to mainatain a healthy
lifestyle. This is due to stress from school and
poor diet control. Educated pt on the
importantance of diabetes control in wound
healing. Encouraged patient to reduce stress and
and use protection.Health History Assessment Essay
Pt will receive the approriate antibiotic when
culture tests are completed. The patient will be
Last Pap smear 4 years ago. Last eye exam in
childhood. Last dental exam “a few years ago.”
PPD (negative) ~2 years ago. No exercise. 24-hour
Diet Recall: States that she skipped breakfast
yesterday, and would typically have a baked good
for breakfast, a sandwich for lunch, and a meatloaf
or chicken for dinner. Her snacks consist of
pretzels or French fries. Immunizations: Tetanus
booster was received within the past year,
influenza is not current, and human papillomavirus
has not been received. She reports that she
believes she is up to date on childhood vaccines
and received the meningococcal vaccine in
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encouraged and impowered to address risky
behavoirs as well.
college. Safety: Has smoke detectors in the home,
wears seatbelt in car, and does not ride a bike.
Does not use sunscreen. Guns, having belonged
to her dad, are in the home, locked in parent’s
room.Health History Assessment Essay
Family History
Patient has a family history of high blood pressure,
high cholesterol and asthma. Patient also has a
family hisotry of cancer with grandparents.
• Mother: age 50, hypertension, elevated
cholesterol
• Father: deceased in car accident one year ago at
age 58, hypertension, high cholesterol, and type 2
diabetes
• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma
• Maternal grandmother: died at age 73 of a
stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a stroke,
history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82,
hypertension
• Paternal grandfather: died at age 65 of colon
cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
• Negative for mental illness, other cancers,
sudden death, kidney disease, sickle cell anemia,
thyroid problems
Social History
Patient is not currently in an exclusive relationship.
She has stopped birth control. She is sexually
active only occassionally and is not consisitent
with contraceptives. Educated patient on the
importance of condoms in pregagncy and
prevention of disease.
Never married, no children. Lived independently
since age 20, currently lives with mother and sister
in a single family home to support family after
death of father one year ago. Employed 32 hours
per week as a supervisor at Mid-American Copy
and Ship. She enjoys her work and was recently
promoted to shift supervisor. She is a part-time
student, in her last semester to earn a bachelor’s
degree in accounting. She hopes to advance to an
accounting position within her company. She has
a car, cell phone, and computer. She receives
basic health insurance from work, but is deterred
from healthcare due to out-of-pocket costs. She
enjoys spending time with friends, attending Bible
study, volunteering in her church, and dancing.
Tina is active in her church and describes a strong
family and social support system. She reports
stressors relating to the death of her father and
balancing work and school demands, and
finances. She states that family and church help
her cope with stress. No tobacco. Occasional
cannabis use from age 15 to age 21. Reports no
use of cocaine, methamphetamines, and heroin.
Uses alcohol when “out with friends, 2-3 times per
month,” reports drinking no more than 3 drinks per
episode. She drinks 4 caffeinated drinks per day
(diet soda). No foreign travel. No pets. Not
currently in an intimate relationship, ended a
three-year serious monogamous relationship two
years ago. She plans on getting married and
having children someday Health History Assessment Essay

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