Assignment 1: Health History Assessment Summary Due Week 3 (Module 2.2) and worth 75 points For this assignment, you will complete a summary health assessment, including a complete health history and physical on an adult client who volunteers to participate and document your findings on this form. Use this Health History Form to document your findings. Submit your completed health history form, genogram, and brief written summary addressing each of the following. Subjective Data: Include and provide great detail of demographic data in health history. Health History: Provide detailed information on the following: Past medical history Past surgical history Current medications, including but not limited to frequency, dosage, and reason for taking the medication Immunization history Social history Health maintenance Family history Patient problem, listed by systems 3. Genogram: Include three (3) generations of family members, clearly state the relationships between the family members, including ages and names. Use appropriate symbols to identify a minimum of three health risk factors across all generations, and causes of death – if known. 4. Summary: Write a detailed summary, strengths, deficits, health-related concerns based on SBAR. 5. Writing: Your assignment should be written clearly, and logically according to APA requirements. The specific course learning outcomes associated with this assignment are: Conduct comprehensive and detailed assessments of health and illness in developmentally and culturally diverse patient populations utilizing cultural awareness, best practices, and evidence-based practice. Conduct appropriate health histories and detailed physical health assessment. Apply information derived from patients’ health histories, genetics / genomics within the context of the health history, genograms, and assessment to formulate an individualized plan of nursing care that focuses on the patient’s individual health promotion and disease prevention needs. Grading for this assignment will be based on answer quality, logic / organization of the paper, and language and writing skills, using this rubric.
Vigor Narrative Mould
The Vigor Narrative involves 2 parts:
- Vigor Narrative
- Summary/Artifice of Trouble
Directions: Conduct a consummate vigor narrative on an adult client and instrument your meetings on this mould. Lastly, you should transcribe a abshope of the vigor of the unrepining that you assess and expand a artifice of trouble (2-3 pages, envelop spaced), which includes vigor risks, media needed, and client teaching requisite to aid vigor. You may excellent the mouldat of this abshope and artifice of trouble. Minimally, you should demonstrate couple measurconducive goals (at lowest undivided that is frustrateative/primary trouble-related) coercion the client, naturalized on the grounds you attentive during the total vigor impost. Manifestation published attraction (guidelines from reputable/specialty organizations and/or lore), to vindicate the artifice of trouble you expand and the goals that you demonstrate coercion the client. Demonstrate interdisciplinary team parts that should be betrothed in the client’s vigorcare, exemplify their roles as parts of this unrepinings’ vigortrouble team and surrender rationales coercion your choices. The managelines adown indicate the impost parameters of each association classification.
Abstract
Many unrepinings trouble from medical contingencys entertain a vigor narrative. The narrative of a unrepining entails pertinent counsel on a unrepining elapsed and offer vigor contingency. The counsel is manifestationd by schoolmistresss to criticise the antecedent vigor contingency, their causes and their texture. From the chronicles a schoolmistrain is conducive to demonstrate excludingtress details that narrate or add to the prevalent medical contingency. A schoolmistrain can tailor a unrepining texture by eliminating textures that did referable performance antecedently and incorporating medication that performanceed. Vigor narrative of a unrepining is collected from antecedent maladyes, texture, association classifications, nativity and gregarious personality. The counsel acts a instrument skillful-treatment coercion a unrepining’s vigor. In this contingency we engage a look at P.M vigor narrative in classify to meet handle coercion her Crohn’s sickness.
Total Vigor Narrative & Corporeal Evidence Mould
Date Consummated: __10/1/2019_____________________________________
Client’s Initials: P.M___ Age: ___50__________________________
Gender: ___Female________________________ Race/Ethnicity: __American
Occupation: _______Teacher___
Marital Status: ___Married
Height: ___5’4___ Weight: 86 kgs
Subsistence Totalergies/Reaction: ______None
Substance Totalergies/Reaction: IV opposition, indispensable to tachycardia
Medication Totalergies/Reaction: Penicillin, reaction hastyes and anaphylaxis
Morphine, reaction hankering occurs
Elapsed Medical Narrative:
Elapsed Surgical Narrative:
Prevalent Medications (Prescription & Over the Counter, including inhalers, persomal medication, restrainteseeing.):
Immunization Narrative (Age Misspend):
Gregarious Narrative
Alcohol Manifestation: Has never consumed alcohol
Tobacco Manifestation: __Locomotive smoker coercion elapsed 30 years_
Drug Manifestation: _None
Narrative of Domestic Violence: ____No chronicles
Sexual Narrative/Practices: ______No chronicles
Occupational Hazards: Long hours of standing
Education: _____Undergraduate
Stressors: ______None
Economic Status: Stable
Religion: _______Christianity
Ethnic Tailground/Cultural Practices: _____None
Dietary Practices: ____Smtotal subsistence portions
Military Service: None
Home Environment: conducive environment
Seat Belt: Offer
Vigor Maintenance
Sleep: _____8 hours a day_
Pressure Skillful-treatment: ___prescribed inferioring drugs
Diet: ___Cold diet
Exercise: ___None
Colonoscopy: ______None
Breast Self-Exams: _________None_
Mammogram: None
Pap Smear (as misspend): None
Lipid Levels (Cholesterol): ______None
Summary
P.M is an American woman who tolerates from Crohn’s Sickness. She is 50 years and a schoolmistrain by avowal. She is married and has couple offspring. P.M has been experiencing extreme abdominal aversion, vomiting, diarrhea and sea-sickness. Antecedent P.M has been diagnosed with crohn’s sickness which was handleed through surgical progress. She so had Adenocarcinoma of final ileum which was handleed through the dispersion of the tooth. P.M tolerates from bipolar disclassify which she rectilineal engage medication. She tolerates posttraumatic pressure disclassify which was diagnosed and handleed.
P.M is totalergic to penicillin that causes anaphylaxis and hasty, morphine that causes hankering and IV opposition that causes tachycardia. P.M lives with her mate and offspring who are total in good-natured-natured vigor contingencys. The unrepining does referable manifestation drugs or alcohol excepting has been a smoker coercion 30 years. The abdominal aversions conversant by the unrepining are characteristics of the crohn’s sickness that looked to flare up intermittently. P.M diets adds to the Crohn sickness becamanifestation it contains smtotal subsistence portions that are cold. The unrepining has referable undergundivided different ordeal hereafter she does referable celebrate her vigor. Her sleeping Patten is okay and she has no pressureors. Her bipolar contingency is a genetic factor that runs in her nativity.
Nativity Narrative (Check the box that corresponds to a disclassify coercion each nativity part that has been diagnosed/unnatural with that malady.)
MGM= Kind Grandmother; MGF= Kind Grandfather; PGM= Paternal Grandmother; PGF= Paternal Grandfather
Comments: PM nativity medical narrative exemplifys that her woman tolerate from bipolar, inferioring and schizophrenia. The experimentations administer to her alcohol addiction which addd to her cessation. Her father is excludingtress with diabetes while her couple sisters entertain hypertension. Her kind grandfather tolerates from leukemia. The bipolar disclassify offer in her woman has been genetically passed on to P.M
Problem List by Classifications (Ask the client if he or she has conversant/ is experiencing the subjoined symptoms/problems. Manifestation this counsel to manage your corporeal evidence.)
Review of Classifications
Summary/ Strengths/Deficits/Health-Related Concerns
P.M peel is very vigory with no lesion, subcutaneous nodules and ulcerations although she is unnatural by hastyes attributable to totalergies. P.M is unctuous and does referable tolerate from any pressure missing or anorexia. Her HEENT evidence pomps that P. M’s ears, eyes, nose and throat are total business and referable unnatural by any contingency. Her respiratory classification is natural, disentangled to auscultation bilaterally and does referable manifestation any accomplice muscles. Cardiovascular of the unrepining has a natural rhythm and murmurs are lukewarm. Gastrointestinal classification of the unrepining pomps fleshiness, a suprapubic surgical scar, hyperlocomotive bowel sounds and natural liver magnitude. The rectal exam pomps insufficiency of hastyes, sores and the guaiac sinstrument ordeal is assured. The neurologic classification of P.M is inconclusive as she experiences aversion and infirmity in her flexure. The unrepining’s musculoskeletal is unnatural by arthritis in her left flexure. P.M tolerateed an wear which causes aversion in her inferior tail. The supernatural evidence pomps pure apprehension and intellect excepting her feelings do modify from era to era.
Diagnostic ordeals on the unrepining pomp the dilation of multiple smtotal bowel loops causing hinderance. The meetings exemplify influence of locomotive Crohn’s sickness in the ileum wrapt by mucosal thickening. The crohn’s sickness flare is incontrovertible gone the unrepining had been antecedently been handleed of the corresponding malady. The unrepining has conversant the exacerbation of the Crohn’s sickness as the abdominal aversions entertain behove sharp. The sicknesss has extraintestinal manifestations by the influence of arthritis on her left flexure. To handle the crohn’s sickness P.M conciliate engage a dosage of prednisundivided 60 mg which she conciliate lessen to 10 mg overera (Hanauer, 2002). Traits of bipolar disclassify are incontrovertible which parent from her woman’s genes. So, the unrepining is diabetic and has hypertension which total look to desire her nativity parts.
Reference
Hanauer, S. B., Feagan, B. G., Lichtenstein, G. R., Mayer, L. F., Schreiber, S., Colombel, J. F., … & Rutgeerts, P. (2002). Maintenance infliximab coercion Crohn’s sickness: the ACCENT I randomised verification. The Lancet, 359(9317), 1541-1549.