health assesment

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NUR2092 WRITE-UP—HEALTH HISTORY

Classroom Assignment Week Two

Date __14th March 2023________________________ Examiner __Veronica Toyin Olatinpo ____________________

1. Biographic Data Name ____BB______

Phone___(312)_111-4521_____________

Address__2038, West Jarvis Chicago,IL 60626_______________

Birthdate __20th March 1989___________

Birthplace _Illinois in Chicago__________

Age ___33_______

Gender _Female_________

Marital Status _Married__

Occupation _Manager____

Race/ethnic origin _African American

Employer __Apple____________________

2. Source and Reliability: The information came from the patient during the verbal assessment

3. Reason for Seeking Care: BB came for the annual checkup, which is her tradition.

4. Present Health or History of Present Illness: N/A

Past Health History

Describe general health _The patient has a positive mindset toward health and plans to improve.

Childhood illnesses _when BB was young, she suffered from measles and chicken pox.

Accidents or injuries (include age) _BB had significant car accidents at 26 and 30, respectively.

Serious or chronic illnesses (include age) _none

Hospitalizations (what for? location?) _had been hospitalized at Schaumburg, Illinois, for pregnancies.

Operations (name procedure, age) _N/A

Obstetric history: Gravida _(# Pregnancies) 1(# Term pregnancies) 1 (# Preterm pregnancies) N/A

Ab/incomplete _N/A-Children living _1 _ (# Abortions or miscarriages) _N/A

Course of pregnancy (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition)

The child's delivery was on June 15th, 2016, after 10 hours of labor pain. The baby was delivered after the complete nine months of the pregnancy. BB delivered a baby girl of 8 pounds and 8 ounces through the virginal delivery. BB did not record any pregnancy complications before and after the delivery of the baby child.

Immunizations_ On the immunizations, BB indicated that she has been vigilant in all the immunizations and was up-date in all the recommended immunizations.

Last examination date: Physical _September 9th, 2021

Dental ___9th June 2019___ Vision _12th May 2018__ Allergies __N/A__ Reaction _None_

Current medications _None _

6. Family History—Specify Which Relative(s)

Heart disease _Grandmother at the age of 65 __ High blood pressure _Grandmother__

Stroke _None_ Diabetes _ Grandmother__

Blood disorders _N/A_ Breast or ovarian cancer_N/A__

Cancer (other): None

Sickle cell: None

Arthritis: None

Allergies: N/A

Asthma: N/A

Obesity: Grandmother and mother

Alcoholism or drug addiction: N/A

Mental illness: none

Suicide: none

Seizure disorder: none

Kidney disease: none

Tuberculosis: none

Review of Systems (Circle/highlight past health problems that have been resolved and current problems, including date of onset.)

General Overall Health State: Present weight (gain or loss, period, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats, or night sweats. BB gained considerable weight at birth in 2016.

Skin: History of skin disease (eczema, psoriasis, and hives), pigment or color change, change in a mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion: The color change also seemed to occur after the delivery in 2016.

Hair: Recent loss, change in texture:

The texture changed after the pregnancy in 2016.

Nails: Change in shape, color, or brittleness

Health Promotion: Amount of sun exposure, method of self-care for skin and hair

BB indicated that she a considerable sun exposure per day. She also utilizes emerging technologies such as Facebook and Youtube to promote self-care for her hair and skin regime.

Head: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo

The patient did not suffer from any of the above conditions.

Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts

Health Promotion Eyes: Wears glasses or contacts, last vision check or glaucoma test, how coping with the loss of vision, if any

The patient does not wear glasses.

Ears: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo

Health Promotion Ears: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears

BB did not complain of any health care condition outlined above.

Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in the sense of smell

BB did not complain of any health care condition outlined above.

Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste

BB was very particular with her teeth and said she does not experience any toothaches.

Health Promotion/Mouth & Throat: Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup

Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter

BB did not complain of any health care condition outlined above.

Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts. Axilla: Tenderness, lump or swelling, rash

BB did not complain of any health care condition outlined above.

Health Promotion Breast: Performs breast self-examination, including frequency and method used, last mammogram, and results

The patient stated that she has been performing self-examining on her breast regularly. The last examination showed that the breasts were okay, with no lumps.

Respiratory System: History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure Health Promotion Respiratory: Last chest x-ray examination

BB did not complain of any health care condition outlined above.

Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify the amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of a heart murmur, hypertension, coronary artery disease, anemia

Health Promotion Cardiovascular: Date of last ECG or other heart tests and results

The patient did not complain of any condition above.

Peripheral Vascular System: Coldness, numbness, and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with the position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers Health Promotion Peripheral Vascular: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose.

The patient did not complain of any condition above.

Gastrointestinal System: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of the abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula)

The challenges of diarrhea and constipation frequency occurred after pregnancy in 2016.

Health Promotion Gastrointestinal: Use of antacids or laxatives

The patient indicates that she does not use laxatives.

Urinary System: Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of the urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in the flank, groin, suprapubic region, or low back

Health Promotion Urinary: Measures to avoid or treat urinary tract infections, use of Kegel exercises

BB indicated that she is avoiding urinary tract infections through kegel exercises.

Male Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia

Health Promotion Male Genital: Perform testicular self-examination. How frequently?

N/A

Female Genital System: Menstrual history (age at menarche, last menstrual period, cycle and duration, amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge, and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.

Health Promotion Female Genital: Last gynecologic checkup, last Pap test, and results

The age at menarche was twelve years, and the result of the last pap was normal.

Sexual Health: Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and your partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptives, and is the contraceptive method satisfactory? Use of condoms, how frequently? Are you aware of any contact with a partner with a sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis)?

The patient indicated that she was in an active sexual relationship where they used condoms during intercourse. Additionally, the patient means that her male partner has no challenge with an erection. Fortunately, the partners have no symptoms or signs of any STDs.

Musculoskeletal System: History of arthritis or gout. In the joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait problems, or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.

The patient did not complain of any condition above

Health Promotion Musculoskeletal: How much walking per day? How does a limited range of motion affect daily activities, such as grooming, feeding, toileting, and dressing? Any mobility aids used?

The patient confirms that she walks approximately 4 miles a day on the weekdays while going and coming out of the working place. She does not use any mobility aids, and any routine activities do not limit her.

Neurologic System: History of seizure disorder, stroke, fainting, and blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or history of mental health dysfunction or hallucinations.

The patient did not complain of any condition above.

Hematologic System: The bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion, and reactions.

Endocrine System: History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, the relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy.

The patient did not complain of any condition above.

Functional Assessment (Including Activities of Daily Living)

Self-Esteem, Self-Concept: Education (last grade completed, other significant training): 12th grade

Financial status (income adequate for lifestyle and/or health concerns): The patient had no health concerns that could affect her finances.

Value-belief system (religious practices and perception of personal strengths): the patient is a Christian and believes that the role of doctors is to treat while God's purpose is to cure.

Self-care behaviors: The patient indicates that she goes for her massage, nails, and hair after every two weeks.

Activity and Exercise: Daily profile, the usual pattern of a typical day: The patient has a busy working day which starts by taking her daughter to school around 8:am; from there, she goes to her work as a manager at Apple company. In the afternoon, she goes to the library, assists her daughter with the homework, and makes dinner for the family.

Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, and climbing stairs: N/A

Leisure activities: During leisure time, the patient enjoys learning how to cook, do makeup, and make wings.

Exercise pattern (type, amount per day or week, method of a warm-up session, method of monitoring: Apart from walking to and from work, she does not engage in any other exercise activity.

Sleep and Rest: Sleep patterns, daytime naps, and any sleep aids used: She indicates that she gets enough sleep, approximately 7 -8 hours. Additionally, she does not use any sleeping aid.

Nutrition and Elimination: Record 24-hour diet recall: The patient embraced three meals that day. The patient took pancakes, eggs, and sausage. She took French fries and fried chicken for dinner and soda and berry donuts as snacks.

Is this menu pattern typical of most days? : Yes, that is what she stated.

Who buys the food? The patient bought the food herself.

Who prepares the food? She prepares the food.

Are finances adequate for food? Yes

Who is present at mealtimes? Her husband, daughter, including herself.

Interpersonal Relationships and Resources: Describe their role in the family: The main role is to help her parents and daughter. She pays all her parents', including medication and rent.

How to get along with family, friends, co-workers, and classmates: the patient indicated that she has a good relationship with all her classmates, co-workers, friends, and families.

Get support with a problem from? The patient gets more assistance from her family.

How much daily time is spent alone? The patient spends approximately 5 hours alone while learning.

Is this pleasurable or isolating? Based on the patient’s argument is that isolating is a pleasurable moment.

Coping and Stress Management: Describe stresses in life now: The patient indicated that the stressor now is to complete her management course to ensure she gets promoted to get more resources to support her family and daughter.

Change(s) in the past year: Losing her job at Walmart Company, where she was getting more salary than his current company, Apple.

Methods to relieve stress: The main relieving methods include meditation, walking, and listening to music.

Are these methods helpful? BB said the methods were very effective.

Personal Habits:

Daily intake of caffeine (coffee, tea, colas) N/A______________________________________

cigarettes? No ____________________________ Number packs per day N/A ______________

Daily use for how many years N/A __________________ Age started N/A___________

Ever tried to quit? N/A ____________________________ How did it go? N/A _____________________________

Drink alcohol? Yes ____________________ Date of last alcohol use 20th May 2021_______

Amount of alcohol that episode approximately 3 glasses of wine _________________________________

Out of last 30 days, on how many days had alcohol? 6 times ____________________________________

Ever told had a drinking problem? No________________________________________________________ Any use of street drugs? No___________ Marijuana? No _________________________________

Cocaine? No __________________________________ Crack cocaine? No______________________________ Amphetamines? No_____________________________ Heroin? __________________

Prescription painkillers? No _____________________ Barbiturates? No_______________________________ LSD? No_____________________________________

Ever been in treatment for drugs or alcohol? No________________________________________________

Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors): The patient indicates that she lives with neighbors in the rental apartment.

Safety of area: The area is safe, having an electric perimeter wall and two soldiers at the get one during the day and the other at night.

Adequate heat and utilities. Yes _________________

Access to transportation: She has a personal car, although taxi is available throughout.

Involvement in community service. No__________________________________________

Hazards at workplace or home No___________________________________________________ Use of seatbelts Yes ____________________________________________________________________

Travel to or residence in other countries. No_____________________________________________ Military service in other countries No___________________________________________

Self-care behaviors involve taking care of her girl and spending time alone during her leisure time.

Intimate Partner Violence: How are things at home? Do you feel safe? The patient indicated that since she was married, they have never been involved in extreme violence. Thus, she feels safe at home.

Ever been emotionally or physically abused by your partner or someone important to you? No___-

Ever been hit, slapped, kicked, pushed, shoved, or otherwise physically hurt by your partner or ex-partner? No______________________________________________

Does your partner ever force you into having sex? No ___________________________________

Are you afraid of your partner or ex-partner? No________________________________

Occupational Health:

Please describe your job: The patient is a manager in the accounting department at Apple Company, where she ensures there is effective bookkeeping. He embraces the servant leadership style of management that involves managing by example. She has a good relationship with all her juniors and seniors at work. She is currently taking a management course that might help her be promoted.

Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? N/A______________________________________________________________________

Any equipment at work designed to reduce your exposure? The patient indicated that she was not aware of any equipment.

Any work programs designed to monitor your exposure? She said she was not ascertain of any__________________

Any health problems that you think are related to your job? No_____________________________

What do you like or dislike about your job? The patient indicated that she dislikes working hours since sometimes it goes beyond nine workers without pay for the extra time.

Perception of Own Health:

How do you define health? She indicated that health is exercising and having proper nutrition and diet while adhering to the doctor's guidance.

View of own health now. The patient indicated wanting to eat healthier, lose weight and avoid major chronic diseases like diabetes.

What are your concerns? The patient's concern was to avoid a chronic illness that previously affected her mother and grandmother.

What do you expect will happen to your health in the future? She said she expects a great life expectancy and maintains her lifestyle.

Your health goals. The patient indicated that her main goals are to continue eating healthy and exercising more.

Your expectations of nurses and physicians: The patient expected physicians and nurses to care for her health as they would like to be cared for in case they are ill.