A Nurse and Patient - Assignment Example

Running head: NURSE AND PATIENT Nurse and Patient Affiliation. Nurse and Patient BIOGRAPHICAL DATA Biographical information 30 year old whitefemale, married, no children. No specific medical conditions to note other than father’s heart surgery at the age of 11. Father has not had any other serious health problems since. Mother has no serious health conditions. Primary language is English. Phone: 555-1978. Address: 5087 Longsville Avenue Los Angeles, CA 90172. SOURCE AND RELIABILITY OF INFORMATION The source seems upfront and very willing to offer honest information. The source has even offered to obtain medical records from other physicians she has seen, if necessary. REASON FOR SEEKING HEALTH CARE Patient must have a reason for seeking health care. Patient states that she thinks she “has a cold.” Symptoms include “exhaustion, runny nose, stuffy head, blurred vision.” The patient also mentioned that it “could be some kind of flu.” HISTORY OF PRESENT ILLNESS (PQRSTU) The patient states that she has been feeling ill for two days. She started to feel a sore throat about 48 hours ago, in the evening, and decided to rest up in hopes of avoiding an illness. She took NyQuil and went to sleep. She woke up with more symptoms, most of them noted above (runny nose, stuffy head, blurred vision.” She states that she has also been under much stress at work and that illnesses have been going around at her work for about two months. Prior to this, she felt fine. PAST MEDICAL HISTORY Address all categories listed below. Childhood Illnesses One case of the chicken pox at 10 years old. No other serious illnesses to note. Patient states that she probably got “one or two colds a year” as a child; this seems pretty average. Accidents One car accident, patient wound up with a broken arm. This occurred at the age of 21. The patient only had a minor fracture—a chipped bone, and recovered fully. No other accidents to report. Chronic Illnesses The patient does not suffer from any type of chronic illness. Hospitalizations One hospitalization from the car accident mentioned above. Patient stayed about 5-6 hours to get her arm examined and placed in a cast. She was then allowed to leave. Operations No operations to report. Obstetric History (if applicable) None to report. Immunizations Patient has had the usual childhood immunizations—measles mumps and rubella shot. The patient also gets a yearly flue shot. Last Examinations The patient’s last examination was two months ago. This was for her yearly physical and blood test. Results were fine. Allergies No allergies to report Current medications Currently the patient is only taking birth control. There are no other medications to report. FAMILY HISTORY Grandfather---Grandmother Grandfather---Grandmother -Aunt----Father-------------------------------------------------Mother Patient--------------Brother—Wife Niece----Nephew On the paternal side, the patient’s grandmother had no serious health issues, but her grandfather died young of a heart attack at 52. Her father also had heart issues at a young age, but surgery at the age of 11 resolved this and he has had no health problems since. On the maternal side, the patient does not know her grandfather. Her grandmother is in good health, as is her mother, and there are no health issues to report there. Her brother, as well as her brother’s children, are also healthy, with no issues to report. REVIEW OF SYSTEMS SKIN – Patient reported mild acne as a teenager, but has not had any skin problems since then. HAIR –Patient’s hair is fine. She has not experienced any recent changes or hair loss. HEAD – Patient has experienced nothing unusual, just states she has a “stuffy head” due to a cold. EYES –Patient states that her eyes have been watery due to her cold. Ears –The patient has not had any issues with her ears. She uses H2O solutions to keep ears clean. Nose—Patient reports some minor discomfort with a stuffy/runny nose due to a cold. Mouth and Throat –The patient is having no mouth pain, but has reported having a sore throat due to her cold. Neck –No pain to report. Breast –No pain to report. Performs self-examinations frequently. Axilla –Nothing to report. Respiratory System: The patient has had some irritability breathing due to her cold. When she did not have the cold, though, she stated her breathing was fine. Cardiovascular –Nothing to report; her heart has been fine. Peripheral Vascular –Nothing to report; she has felt fine. Gastrointestinal. She has not had any issues with her gastrointenstinal tract that have been out of the ordinary. Female Genital System. Menstrual history has been fine and regular. Age 13 at menarche. Last menstrual period was three weeks ago. She does not experience premenstrual pain or discomfort. She gets a once yearly pap and checkup, and her results were fine. Sexual Health. Presently in a relationship involving intercourse? Not presently in a relationship involving intercourse. Musculoskeletal System: Nothing to report. Patient works out regularly; three times a week, on a treadmill. Nuerologic System: Patient has not had any history of this. Health Promotion: Patient has a steady relationship with her family. Hematologic System –No problems here. Endocrine System – No problems to report. FUNCTIONAL HEALTH Self concept Patient has a healthy self-concept. Believes in her self-worth and feels she is very proud of her work. Activity/Exercise Patient works out at least 3 times a week. Sleep/Rest Patient makes sure to get at least 8 hours of sleep each night. Patient reports no problems with sleeping. Nutrition/Elimination Patient watches what she eats and believes in eating healthy. Interpersonal Relationships/Resources Patient has a close relationship with her mother and brother, and relies on them for support. Spiritual Resources None to report. Coping and Stress Management Patient believes in stepping away from the problem, recovering, and then trying to address the problem. Personal Habits Patient has very healthy personal habits and is very aware of personal hygiene. Alcohol/Street Drugs Not used. Environmental Hazards She is not exposed to any. Intimate Partner Violence She is not exposed to any. Occupational Health The patient works in a clean office and is not exposed to any risky areas in that concept. PERCEPTION OF HEALTH The patient has a realistic perception of health. Overall, she believes in working out and eating right to keep herself healthy. She also involves herself in supportive interpersonal relationships through her interactions with her family. CULTURAL ASSESSMENT- SUMMARY OF THE FOLLOWING AREAS 1. What ethnic or cultural group do you identify with? White, middle class Identify one or two specific health care beliefs or practices for this group. Working out at least three times a week. a. How closely do you follow these beliefs or practices? Always work out unless there is an illness. b. Are there any barriers to communication with health care providers? How are these addressed? Currently there have been no barriers. 2. Are you a spiritual person? Tell me about that. Not a spiritual person. a. Are you member of a religion? If so, which one? Not a member of a religion. b. Tell me about one or two beliefs or practices that you would want a health care provider to know about. Belief in exercise and desire to eat healthy. c. How closely do you follow these beliefs or practices? These are followed closely on a daily basis. 3. Do you use any cultural or alternative (i.e. not based on Western medicine) healing practices? If so, describe. Note to students: remember to ask about herbal preparations or “home remedies”. Not currently. NOTE: Person may give you information about any or all of these a. Customs, practices or beliefs about health b. Customs, practices or beliefs about illness c. Customs, practices or beliefs about death d. Customs, practices, or beliefs related to food e. Any other specific practices of the group or the family when someone is ill Not currently. Read More