need help with health promotion assesment

NUR335Assignment5.1HealthPromotionAssessmentWorksheet.pdf

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Denver College of Nursing

NUR 335 Prac7cum Assignment 5.1

Health Promo7on Assessment Worksheet

A health promo,on assessment is a targeted assessment where the nurse assesses for health risks and educa,on gaps that can be improved through health promo,on interven,ons

Use this worksheet to interview an individual. There is a sec,on at the bo<om for you to add addi,onal assessment informa,on. Document your findings on the worksheet

Demographics

Ini7als: __td______________ Age:_____28______________ Sex: ____female_______________

Primary Language Spoken: ___english____________ Cultural Background:_______american_____________ ______________________________________

General Health

How would you rate your general health? I think my general health is good despite my type 1 diabetes on a 0-10 scale id rate it an 8

Have you had a wellness checkup with a healthcare provider in the past year?

Yes

Have you ever been told by a health care provider that you have a chronic disease such as hypertension, diabetes, heart disease, stroke, arthri,s or kidney disease?

Yes I have type 1 diabetes

In the past month, have you had pain on more than three days that impacted your ability to perform your normal daily ac,vi,es? If yes:

• Where was the pain located? • What have you tried to relieve the pain?

No pain

How would you rate the quality of your sleep? • How many hours do you regularly sleep in

a night? • Do you ever wake up before you wanted

to? • Do you have problems falling asleep?

i sleep about 8 hours a night I do wake up usually to use the bathroom I don’t typically have problems falling asleep

Medica7ons

Are you currently taking medicine for any chronic condi,on?

• Do you know what the medica,on is used to treat?

• Have you missed doses of your medica,on in the last week?

I take insulin its used to treat my high blood sugars I haven’t missed any doses

Women Only:

Are you pregnant or planning on becoming pregnant in the next year?

A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?

• If yes, when was your last mammogram?

Yes i had one when I was 20

A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?

• If yes, when was your last Pap test?

I get one yearly im due in January

Men Only:

A PSA test is a test for cancer of the prostate. Have you ever had a PSA test?

• If yes, when was your last PSA test?

I have not

Lifestyle

Do you now smoke cigare<es every day, some days or not at all?

• If you are currently smoking, have you tried to quit?

• If yes, what methods have you used to quit smoking?

o Were the methods successful?

I don’t smoke

For the ques7ons below consider the past week in your answer:

How many ,mes did you take part in physical ac,vity of at least 30 minutes during the past week?

• If yes, what type of physical ac,vity? • If no, why? • Was the past week representa,ve of your

normal level of physical ac,vity?

I usually walk alot at work, about 3 7mes a week on the floor. This is a typical week for me

How many hours a day in the past week do you think you spent on sedentary ac,vi,es where you remained siMng for extended periods of ,me?

• What ac,vi,es were you doing during these ,mes?

Probably more then I should id say about 10 hours of watching tv

To the best of your recollec,on, what food items have you eaten for breakfast in the past week?

Mostly biscuits I eat them a lot

To the best of your recollec,on, what food items have you eaten for lunch in the past week?

I usually eat sandwiches and chips for lunch

To the best of your recollec,on, what food items have you eaten for dinner in the past week?

Some7mes I skip meals depending on the day but for dinner I probably had chicken

What beverages do you rou,nely drink? • How many ,mes per week did you drink

soda or pop? • How many glasses of water do you drink

in a day?

I drink all diets mostly diet mt dew

Do you eat snacks throughout the day? • If yes, what snacks do you rou,nely eat? • What ,me in the day do you regularly eat

snacks?

Yes I have to in order to keep my blood sugar up typically they are nabs

How many ,mes per week have you skipped meals?

For the ques7ons below consider the past 30 days in your answer:

What is the largest number of alcoholic drinks you had on any occasion in the past 30 days?

None

Have you used any drugs or other substances, other than those that are prescribed for medical reasons?

• If yes, what substance(s) did you take? • How many ,mes have you used this

substance in the past 30 days?

In the past 30 days, how many ,mes have you eaten a meal outside of the home; at a restaurant or other venue?

Yes

For the ques7on below, consider all lifestyle behaviors (combined) in your answer:

Do you believe you lead a healthy lifestyle? Please explain your answer?

I think I lead a pre^y healthy lifestyle I don’t eat a lot of junk foods

Mental Well-Being

How oQen do you experience stress that exceeds your ability to cope?

• What strategies do you use to control stress?

I don’t

How oQen do you get the emo,onal and social support you need?

• Who would you describe as your support system?

I get a lot of emo7onal and social support from my friends and family

Over the last two weeks, how many days have you felt down, depressed or hopeless?

• If you have felt these feelings, what ac,ons did you take to make yourself feel be<er?

I have felt great the last few weeks not feeling down depressed or hopeless

Access to Preventa7ve Services

Do you feel you have access to preventa,ve health screenings and educa,on?

• Do you have health insurance? • Have you ever skipped care (Prescrip,ons,

therapy, specialist visits etc.) that was recommended to you because of concerns regarding the cost of the care?

Yes i do feel like I have access to preventa7ve health screenings. My job provides health insurance I have never skipped care.

Educa7on

Where do you normally receive health informa,on? Examples could be the internet, health care provider, family or friends, etc.

I receive health informa7on from my drs office friends and family and some7mes co workers because I work in the medical field

What health topic(s) would you like to have more informa,on on, if available?

Diet and nutri7on

To be filled out by the par7cipant:

Which of the following describes you, regarding each of these ac,vi,es?

I have considered healthier choices when it comes to diet

I am sa,sfied with my weight at this ,me.

I have considered healthier choices when it comes to exercise.

I am sa,sfied with my choice not to smoke tobacco.

I am sa,sfied with the way I handle stress.

I am sa,sfied with my sleep regimen.

I am sa,sfied with not drinking alcohol.

Other Assessment Informa7on

Adapted from the CDC Na,onal Healthy Worksite Program (NHWP) Employee Health Assessment (CAPTURETM)