NR 226week 3

Assignment Sections and

Required Criteria

Assessment Documentation

Reference Citations (If needed)

Health History

Demographic data:

The patient is a 45-year-old African Female who resides in Maryland area. She is a non-smoker, consumes alcohol occasionally, and works as a construction manager. He lives with his wife and two teenage children.

Reason for care:

The patient came for a routine annual check-up and complained of shortness of breath but only during an exercise for the last three months.

Present illness (PQRST of current illness):

P: The shortness of breath occurs during moderate physical exertion, such as climbing stairs. Q: The patient describes it as mild but noticeable. R: It is located in the chest and does not radiate. S: The severity is rated 3/10. T: It has been occurring intermittently for about three months and usually lasts for a few minutes.

Perception of health:

The patient considers herself healthy although she is not sure what contributes to the new development of shortness of breath and the possibility of aging or lack of exercise. He is concerned about his health and wants to avoid any complications as those associated with the heart.

Past medical history (including medications, allergies, vaccinations, and immunizations):

It has been noted that the patient has a history of hypertension that is managed with lisinopril 10 mg daily. According to the records, she has no history of allergies. Immunizations are in accordance with current recommendations, including annual influenza vaccination and tetanus, toxoid booster in the past five years.

Family medical history:

The patient's father had a history of coronary artery disease and passed away at 60 years dues to a myocardial infarction. His mother is alive and has type 2 diabetes, managed with diet and oral hypoglycemics. He has one sibling, a younger brother, who is in good health.

Review of systems:

General: No weight loss, fever, or fatigue. Skin: No rashes or lesions. HEENT: No headaches, vision changes, or hearing loss. Respiratory: Occasional shortness of breath during exertion. Cardiovascular: No chest pain, palpitations, or edema. Gastrointestinal: Normal appetite, no nausea, vomiting, or abdominal pain. Musculoskeletal: No joint pain or stiffness. Neurological: No dizziness, syncope, or weakness.

Developmental considerations (using Erikson’s Stages of Psychosocial Development):

The patient is in the "Generativity vs. Stagnation" stage, where she is focused on contributing to society through his work and caring for his family (Gross, 2020). He expresses satisfaction with her career and family life but is concerned about her health as it impacts her ability to provide for her family.

Gross, Y. (2020). Erikson's stages of psychosocial development.  The wiley encyclopedia of personality and individual differences: Models and theories, 179-184. https://doi.org/10.1002/9781118970843.ch31

Cultural considerations:

This patient has an ideal of being a family-oriented person and wants to alter her daily lifestyle to afford the medication so that she can continue supporting her family. She also mentions the influence of her family in the health decisions that she takes in his life.

Psychosocial considerations:

The patient reports no sign of stress and have support in his family. He has a stable social network and participates in community activities, which he finds relaxing and fulfilling.

Presence or absence of collaborative resources:

The patient is in a position to attend medical check-ups frequently through the health insurance cover provided by his employer. He is also a member of a local community focused on encouraging their fellow community members to engage in regular exercise and eating healthy, which he states is helpful in managing his own health.

Physical Examination:

Objective Data

HEENT (head, eyes, ears, nose, and throat):

The head is normocephalic and atraumatic. Eyes are without conjunctival injection, and pupils are equal, round, and reactive to light. Ears are clear without discharge. The nose is patent bilaterally without lesions. The throat is clear with no tonsillar enlargement.

Neck (includes thyroid and lymph chains):

The neck is supple without lymphadenopathy or thyromegaly. Trachea is midline. No jugular venous distention.

Respiratory system:

Breath sounds are clear bilaterally. No wheezes, rales, or rhonchi. The patient exhibits normal respiratory effort with no use of accessory muscles. The chest wall moves symmetrically with respiration.

Cardiovascular:

S1 and S2 are present with a regular rate and rhythm. No murmurs, gallops, or rubs. Peripheral pulses are 2+ bilaterally. No carotid bruits or peripheral edema noted.

Neurological system:

The patient is fully oriented to the person, place, and time. Facial nerves are normal and include cranial nerves II-XII. The strength of the motors is full five in both upper and the lower limbs and sensation also is normal. Reflexes are 2+ and symmetrically present on both sides of the body. Motor function: No postural or kinetic tremor, no incoordination, and no unsafe or unusual movements.

Gastrointestinal system:

The abdomen is soft, non-tender, and non-distended. Bowel sounds are present in all four quadrants. No hepatosplenomegaly or masses palpated.

Musculoskeletal system:

Full range of motion in all joints with no swelling or deformity. The patient exhibits normal gait and posture. No joint pain or stiffness reported.

Peripheral vascular system:

No varicosities or signs of deep vein thrombosis. Capillary refill is less than 2 seconds. Peripheral pulses are palpable and symmetrical in all extremities.

Needs Assessment

Based on the health history and physical examination findings, determine at least two health education needs for the individual. Remember, you may identify an educational topic that is focused on wellness.

Health promotion that would be valuable for the conveniently enrolled patient would involve education of cardiovascular diseases, hypertension risk factors, alongside improving respiratory health through recommended physical activities (Dhindsa et al., 2020). Furthermore, the present study should involve outlining stress management strategies to minimize the level of stress that emanates from the workplace and consequently improve health.

Dhindsa, D. S., Sandesara, P. B., Shapiro, M. D., & Wong, N. D. (2020). The evolving understanding and approach to residual cardiovascular risk management. Frontiers in Cardiovascular Medicine, 7, 88.

Support the identified health teaching needs selected with evidence from two peer-reviewed journal articles.

Dhindsa, et al., (2020) also found that there is a need to educate patients with hypertension on cardiovascular health to avoid the risk of experiencing heart disease. Regarding stress, it has been established that it lowers the likelihood of cardiovascular occurrences (Yen et al., 2022).

Dhindsa, D. S., Sandesara, P. B., Shapiro, M. D., & Wong, N. D. (2020). The evolving understanding and approach to residual cardiovascular risk management. Frontiers in Cardiovascular Medicine, 7, 88. https://doi.org/10.3389/fcvm.2020.00088

Yen, F. S., Wei, J. C. C., Chiu, L. T., Hsu, C. C., & Hwu, C. M. (2022). Diabetes, hypertension, and cardiovascular disease development. Journal of Translational Medicine, 20, 1-12. https://doi.org/10.1186/s12967-021-03217-2

Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education.

The patient's developmental stage and cultural values emphasize the importance of family and career, which can motivate him to adhere to health education that allows her to continue fulfilling these roles. However, her work-related stress and potential cultural stigmas about seeking mental health support could act as barriers to effectively managing stress and maintaining cardiovascular health (Yen et al., 2022).

Yen, F. S., Wei, J. C. C., Chiu, L. T., Hsu, C. C., & Hwu, C. M. (2022). Diabetes, hypertension, and cardiovascular disease development. Journal of Translational Medicine, 20, 1-12. https://doi.org/10.1186/s12967-021-03217-2

Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) affect proposed teaching.

The patient's strong family support and active involvement in community health initiatives are significant strengths that can positively influence the success of health education interventions. Her access to healthcare resources through her employer and community groups further supports the likelihood of positive health outcomes (Yen et al., 2022).

Yen, F. S., Wei, J. C. C., Chiu, L. T., Hsu, C. C., & Hwu, C. M. (2022). Diabetes, hypertension, and cardiovascular disease development. Journal of Translational Medicine, 20, 1-12. https://doi.org/10.1186/s12967-021-03217-2