Focused assessment (skin)
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HealthHistoryROSandCulturalAssessment.docxHEALTH HISTORY, ROS, AND CULTURAL ASSESSMENT 2
HEALTH HISTORY, ROS, AND CULTURAL ASSESSMENT 3
Health History, ROS, and Cultural Assessment
Svetlana Alpin
Dr. Linda Brown
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.
