Subjective Data Collection from a Patient Who Has Multiple Sclerosis - Essay Example

Current Symptoms: the patient denies any abdominal pain or any other related complications

Past History: The patient has no history of any related abnormal pain except for constipation that sometimes causes her pain and frustration. This occurs when she takes a certain type of food that she deceases from taking on realizing that they are major contributors to the same problems (Mesbah, Cole, and Lee, 2002).  

Family History Denies any family history of abdominal pains.

Lifestyle and Health Practices: Evading eating food materials that lead to stomach pain. Taking a lot of fiber-containing food and taking mixing foods/ or dishes at the same meal.

2. Record in a narrative format your subjective data findings from your client for musculoskeletal using page 178 (Activity E) in your lab manual and the following headings:

Current Symptoms: Reports musculoskeletal that affected her knees and that this contributed to being placed in the wheelchair. Her joint pains are usually severe and prolonged.

Past History: The musculoskeletal problems started in her late 40s. The pain has been consistent and severe. She also feels fatigued and disturbed sleep that reoccurs almost every night.

Family History: There is no clear indication that the same problem has reflected in her family line. However, her grandfather from the father’s was at one point diagnosed with some mild signs of musculoskeletal (Sasson, 2008).

Lifestyle and Health Practices: Taking pain relievers and before they set her in the wheelchair, she used to do some walking exercises. Additionally, she is being massaged at the joint to keep them functional as a means of exercising them.

3. Record in a narrative format your subjective data findings from your client for a nervous system using pages 189-190 (Activity E) in your lab manual and the following headings (Omit Analysis of Data section) (Weber, Kelly, and Sprengle, 2014):

Current Symptoms: No reports of blood supply problems, no signs of exposure to toxic substances (carbon dioxide, lead, and or arsenic among other toxic elements); however, the patient suffers a severe central nervous system disorder from the gradual loss of function; the Multiple Sclerosis (MS).

Past History: The patient reports that at age of 32 years, she did suffer muscle imbalances and control that did lead to a loss of strength. At some point at the age of 35 years, she was diagnosed with optical nerve disorder that led to infections of her eyes (Mesbah, Cole, and Lee, 2002).

Family History: The patient’s father was diagnosed with the central nervous disorder in relation to the optic disorder. However, he did not show any signs of multiple sclerosis. He died without developing any disability.

Lifestyle and Health Practices: taking medicine among other drugs that have been subscribed to the same disorder. Exercising and having a massage on the joints and having maximum rest whenever the levels of the pain go down.

4. Record in a narrative format your subjective data findings from your client for mental status using pages 29-30 (Activity C) and the following headings (Weber, Kelly, and Sprengle, 2014):

Biographical Data: the patient is female aged 53 years, with a weight of 115 lbs and 5’4. She is a mother of two kids who are in college (Sasson, 2008).

Present History (with COLDSPA): she is suffering from multiple sclerosis to which she was diagnosed at the age of 32 years. She lives at home under home care who attends to her 3 times a week and her husband taking care of her for the rest of the days. She has no strength; thus, being transferred from the chair to bed with maximum assistance. The patient has never been diagnosed with any mental problems (Mesbah, Cole, and Lee, 2002).

Past Health History: the patient has got no history of mental related problems.

Family History: no records of any history of mental problems within the patient’s family linage.

Lifestyle and Health Practices: under medication among other health practices taken care of by a home healthcare provider.

5. Record in a narrative format your subjective data findings from your client for general status using page 45 (Activity D) in your lab manual and the following headings (this may be copied from week 1 assignment) (Weber, Kelly, and Sprengle, 2014):

Present History (with COLDSPA): the patient is suffering from multiple sclerosis a situation that has placed her in a wheelchair. She is under the home healthcare provider as well as close family care.

Past History: suffered the same condition that affected her central nervous system at the age of 32 years old.

Family History: only her father was diagnosed with a mild condition of central nervous disorder.

Lifestyle and Health Practices: taking medication under the close supervision of a home healthcare provider and her husband. She also feeds on a well-balanced diet with a lot of iron adding foods and fruits as well as vegetables.