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HealthHistoryROSandCulturalAssessment.docx

HEALTH HISTORY, ROS, AND CULTURAL ASSESSMENT 2

HEALTH HISTORY, ROS, AND CULTURAL ASSESSMENT 3

Health History, ROS, and Cultural Assessment

Svetlana Alpin

Broward College

NUR 3069L

Dr. Linda Brown

October 23, 2018

Running head: HEALTH HISTORY, ROS, AND CULTURAL ASSESSMENT 1

Health History, ROS, and Cultural Assessment

CHIEF COMPLAINT

Patient presents to clinic with complaints of pain in her left inguinal area.

HISTORY OF PRESENT ILLNESS

Mrs. H. is 40 years old, Hispanic female with no known drug/food/environmental allergies presented today with an intermittent sharp pain that started in her left inguinal area of one-week duration. The pain gets worse when she is not taking Motrin, which she was taking for four days. States that it is her first time having that type of pain reports the pain level of 8/10. Describes her pain as sharp and radiating towards her left flank area. States that pain is making her tired, which limits her daily activities. She denies lifting heavy objects or being involved in an accident, states that pain doesn’t get better with rest. Weight gain of five pounds noted in the past two months. Denies any difficulty on urination, or blood in urine/stool, no diarrhea or constipation, no fever reported. Denies being pregnant, last menstrual period 10/15/2018, no abnormal bleeding during the last period. (Jensen, 2015).

MEDICATIONS:

Naproxen 600 mg every six hours as needed for pain

Motrin 600 mg every 8 hours as needed for pain

ALLERGIES: no known drug/food/environmental allergies.

SOCIAL HISTORY

Tobacco Use: none

ETOH use: none

Illicit drug use: none

Born in: Bogota, Colombia

Education: Undergraduate Registered Nurse

Occupation: Operating Room Nurse

Family Situation: Married

Interest/Hobbies: Travelling, reading, cooking

PAST MEDICAL HISTORY

Thalassemia diagnosed in 1998.

Herniated lumbar discs, L-4 and L-5 diagnosed in 2005

PAST HOSPITALIZATIONS

none

PAST SURGICAL HISTORY

Ovarian Cystectomy in 2016

VACCINATIONS

Flu: none

Pneumovax: not applicable

Tetanus: May 2010

FAMILY HISTORY:

Father: alive; Hypertension, Peripheral Vascular Disease

Mother: alive; healthy

Grandparents:

Paternal grandfather: alive, 91 years old, healthy.

Paternal grandmother: deceased from kidney failure, history of peripheral vascular disease, hypothyroidism.

Maternal grandfather: not known

Maternal grandmother: deceased from heart attack.

Brother: two brothers, alive; healthy

Sister: none

Children: none

REVIEW OF SYSTEM:

 

Concerning Symptom

Findings

 

General

Weakness, fatigue, weight increase

 

 Denies fever

Skin

None

Denies rash; lumps; sores; itching; dryness; color change in hair/nails

Head

None

 Denies headache, head injury, dizziness

Eyes

 

None

 Denies vision changes, wears glasses, last eye exam 10/2017, denies pain, redness, excessive tearing, double or blurred vision, as well as scotoma.

Ears

None

 Denies hearing changes, tinnitus, earaches, discharges, denies, redness or swelling.

Nose/

Sinuses

None

 Denies colds, congestions, discharge, itching, hay fever, nosebleeds.

Throat

None

 Denies bleeding gums; dentures; sore tongue; dry mouth; sore throats; hoarseness;

last dental exam on 04/10/2018

Neck

None

Lumps; swollen glands; goiter; pain; neck stiffness

Breasts

None

Denies any lumps; pain; discomfort; nipple discharge

Pulmonary

None

 Denies cough: productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains

Cardiac

None

 Denies chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema

G/I

None

Denies appetite changes; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance

Urinary

None

 Denies frequency; nocturia; urgency; dysuria; hematuria; incontinence

G/U

(General)

None

 Heterosexual; interest in men; function appropriate to age; satisfaction; no use of birth control methods; HIV exposure occupational

Female G/U

None

Menarche at age of 12; frequency: regular, monthly /duration of menses: 5-7 days; denies dysmenorrhea; PMS symptoms: increased appetite, mood swings, back pain. Denies bleeding between menses or after intercourse; LMP on 09/30/2018.

Denies vaginal discharge; itching; sores; lumps. Denies symptoms of menopause such as hot flashes, headache, insomnia.

Peripheral Vascular

None

 Denies pain, claudication; leg cramps; varicose veins; hx of blood clots.

Musculo-skeletal

Reports pain in the lower back and left calf.

Denies joint pain; joint stiffness

Neuro

None

Denies syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements

Heme

Reports Hx of anemia (Thalassemia)

 Denies easy bruising or bleeding; blood transfusions

Endo

None

Denies heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size change.

Psych

None

Denies nervousness/anxiety; depression; memory changes; suicide attempts

CULTURAL ASSESSMENT:

Patient, L.H., is a pleasant 40-year-old married Hispanic female. English-speaking, literate in reading and writing; talkative, open, and cooperative. The patient is of Colombian descent, born and raised in Bogota, Colombia. Patient values education, financial resources that allow her to have a quality life, and loves working as an Operating Room nurse. She treasures her free time and enjoys spending it with her husband, her dog, and other family members, as well as with her friends. The patient is practicing Christianity and goes to Sunday services at her church every week. She doesn’t have any children yet but would love to have two or three later. The patient loves eating Colombian food but recently starting to adhere to Weight Watcher’s diet. The patient believes in natural medicine, doesn’t get vaccinated for flu, and tries to avoid taking medications.

NANDA #1

Acute pain related to altered hormone levels and cyst formation as evidence by patient’s report pain of 8 on a scale of 1-10.

NANDA #2

Fatigue related to acute pain as evidenced by patient reporting she feels tired, and unable to maintain her daily routine.

PLAN OF CARE:

Communicate the assessment findings with MD and medicate the patient for pain as ordered, reassess pain after administration. Provide a comfortable and relaxing atmosphere by dimming the lights, make sure the patient’s environment is quiet and free of stimuli. Follow the orders for blood work and diagnostic examinations as soon as prescribed.

Reference

Jensen, S. (2015). Nursing health assessment: A best practice approach. Philadelphia: Wolters

Kluwer Health.