Health Assessment (NUR 220)
Health Assessment (NUR 220)
Health History Admission Database Patient Name: Angelina Jolie DOB: 10/25/1967 Age: 54 MRN: 123456 Preferred Name: Angie POA/Spokesperson: Brad Pitt Reason for visit/seeking care: Annual Checkup Demographic Data Living Arrangements/Others in household: Patient live with her husband and her 12-year-old disabled daughter, as well as a full-time nanny and an international student in a house. Occupation: Lawyer Level of Education: Law degree Ability to Read/Write English: Yes Primary and Secondary languages: English Religion: Jewish Religious or cultural beliefs or practices that impact healthcare or could impact a hospital stay: No Race: Caucasian Ethnicity: Non-Hispanic Additions/Comments: Patient is competent to provide information, preferred pronounce is she/her, and gender identity is female. Medical History Allergies to medications and reactions: Penicillin – causes hives. Environmental allergies and reactions: Pine trees, and allergy induced asthma. Patient does not use any medications for allergy, accept Albuterol 1actuation for asthma which she takes only when needed. Chronic medical conditions and impact: Fibromyalgia – causes pain and discomfort in upper bilateral extremities, fatigue, insomnia, stiffness in her joints in the mornings, along with depression and anxiety. Patient also states that the pain gets worse in the winter months because of the exposure to cold temperatures. Patient states that her fibromyalgia is well managed with her medication.
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Hypertension – patient did not complain/stated about any symptoms. Patient stated that occasionally she gets headaches when her blood pressure gets to high. Patients’ blood pressure, however, is well managed with medication. Asthma – when patient has an episode she struggles to breath, her chest gets tight, and she gets restless. This symptom is resolved within about 5 minutes of using her asthma inhaler. Gastroesophageal reflux (GERD) – occasionally the patient gets heartburn and is sometimes worse when earing certain food (acid/spices). Patient also states that occasionally she gets severe heartburn and hoarseness when she forgets to take her medication. However, the patient states that her GERD is well managed with medication. Previous surgeries/year/impact: 1985 – Rhinoplasty – for cosmetic reasons. 1987 – Foot surgery – patient states that she broken some bones in her foot during a ski accident and had to get surgery. 2004 – Appendectomy – patient states that her appendix got inflamed and had to be removed 2006 – Ovarian cyst removal Problems with anesthesia? None Objections to blood or blood products? None Prescription medications: dose, route, frequency, and reason for prescription: Prinivil 5 mg once daily, PO, for hypertension Omeprazole 100 mg once daily, PO, for gastroesophageal reflux. Duloxetine 60 mg once daily, PO, for fibromyalgia and anxiety Albuterol 1actuation, 90 mcg, inhalation, for asthma – as needed. Over the counter medication use and frequency: Advil: 200-400 mg as needed (once a day), PO, for pain Vitamin D supplements: 400 IU daily, for vitamin D deficiency. Use of herbal products, complementary therapy, or alternative therapy: None
Previous hospitalizations: Patient has no recent hospitalizations, or any long-term hospitalizations 2018 – Colonoscopy – patient went home after procedure and was not hospitalized 2009 – Pericarditis – patient was admitted for 5 days 2006 – Ovarian cysts removed – patient was admitted for one day 2004 – Appendectomy – patient was admitted for one day 2008 – Labor – patient was admitted for one day 1996 – Labor – patient was admitted for one day 1987 – Foot surgery – patient was admitted for one day 1985 – Rhinoplasty – patient went home after procedure Previous Injuries: Patients states that she had no recent injuries. Foot injury in 1987 – ski accident 2 Additional questions/ patient response: How does your allergies impact your daily life? Patient states, that the allergies do not impact her daily life except during allergy season (Spring and summer). During these months, the patient claims that she has to take her asthma inhaler with her when she wants to do physical activities and exercise. Patient also states that rarely she would wake up during night and struggle to breath, and when she uses her inhaler it keeps her up all night. How does your previous injuries impact your daily life? Patient states since her ski accident she cannot run anymore, which caused some weight gain. Patient also states that she has to wear special shoes (orthotic shoes) otherwise her feet is in a lot of pain. How do you feel after taking your medication? When taking my asthma inhaler, it helps alleviate symptoms of SOB chest pain. Patient states that the fibromyalgia relieves pain in her arms and relieves some of her anxiety (patient made a funny comment stating that she does not know if the relieving of the anxiety is just a “mental thing”). Patient states that the GERD medication is effective since she mostly experiences symptoms of heartburn only when she forgets to take her medication. Patient states that she did not feel good at the onset of starting her hypertension medicine, but now she feels better, and she has no concerns about her hypertension. Patient also states that since she started using vitamin D supplements, she feels more energetic. Health Maintenance Last physical exam: 02/01/2020 Last Dental Exam: 12/13/2020 Dentition: Good oral health Any implanted medical devices: None BSE/TSE (breast self-exam/testicular self-exam): Patient does not do BSE but goes routinely every 6 months for mammogram. Patients last mammogram was December 2020, and no lumps or masses was detected. Female: X last menstrual period 02/05/2021 pregnancies 1996 and 2008 live births 2 Immunizations (developmentally appropriate questions): Patient gets the flu shot every year since she was a teenager Patient received all her vaccinations as a baby Sleep and Rest Patterns: Patient goes to sleep around 10/11pm and wakes up in the morning around 6/7am. Patient has a disabled daughter that needs assistance throughout the night. Patient states on a good night she might get 6 hours of sleep, but on average she gets about 5 hours of sleep. Leisure and Exercise Activities: Skiing in the winter months and golfing some weekends in summer. Tobacco use: None Alcohol use: Occasionally (2/3 per month) Have you ever felt the need to Cut down on your drinking? Yes No Have you ever felt Annoyed by criticism of your drinking? Yes No Have you ever felt Guilty about your drinking? Yes No Have you ever had the need for an “eye-opener” to each a hangover or as a nerve steadier? Yes No
Recreational Drug use: Never Psychosocial Family and social relationships: Husband, and one 12-year-old daughter along with a full-time nanny and an international student. Are you in a relationship in which another person tries to control you? Yes No Has anyone physically harmed you in any way in the last twelve months? Yes No Do you feel safe at home? Yes No Current stressors: Patient states that running a business is stressful along with a little sleep every night for the past 12 years is catching up to her. Patient also states taking care of her daughter gets hard sometimes and she is always worried about her and always tried to do the best for her. Patient also states that the pandemic is stressful since it has a financial impact on most people. Currents pain issues: Patient states that she occasionally has back pain, but she takes Advil to relieve the pain. Patient also complains about pain in her arms, hands, and shoulders (bilateral upper extremities) associated with her fibromyalgia, but her medicine does help to relieve some of the pain. Impact of pain or stress on your life or self-concept: Yes, sometimes the patient can’t go to work, and cant part take in family activities like skiing, golfing, and going out to socialize with friends and family. Mental health diagnosis or concerns: Patient states that she has no diagnosis. However, she sometimes feels depressed and anxious, but she think it is a “normal” feeling that most parents with disabled children experience. Patient states that her anxiety and depression started when she discovered that her daughter has special needs and that it got a little worse as soon as she was diagnosed with fibromyalgia. Patient does not have any major concerns about her mental health.
2 Additional questions/ patient response: How does your anxiety and depression impact your daily life? Patient states that it does not impact her negatively, she just always wants to make sure her daughter gets everything that she needs. It sometimes prevents her from focusing on her work and to get everything done that she needs to get done. Patient states that she thinks it is “normal” to have these feelings given all her circumstances. How is your relationship with your family? Patient has a good relationship with her family, and she has a busy household. She states that having a full-time caregiver help’s a lot. Her parents live in Florida in the winter months and comes back home to Cleveland in the summer months, during the winter months she and her daughter misses her parents a lot. Patient states that everyone in the household has a healthy relationship and everyone works well together to take care of her daughter and to get everything done. How does your pain impact your daily life? Patients says that sometimes she cannot go to work because the pain is just too much. Patient states that since she runs her own business, if she does not go to work, she does not make money, thus it impacts her business occasionally. Patient also can’t lift her daughter anymore and thus always needs to call someone to help her change her daughter. Activities of Daily Living Assistive Devices: None Implanted Devices: None Transportation: By car Use of community Services: No Dietary Needs or practices: None Issues with swallowing or other issues interfering with digestion: No issues with swallowing but struggles with acid reflux after ingesting foods rich in acid and spices. Issues interfering with the ability to obtain or prepare food: None
Any gain or weight loss in the last three or four months: Yes, 10 pounds in the last 4 months, due to COVID, and being inactive. Additions/Comments: Patient claim that she does not have any issues with swallowing or digestion, but occasionally struggle with acid reflux. Patient does take omeprazole for acid reflux. Patient claim weight gain is due to the pandemic and that she is not as active as she used to be. Learning Needs Preferred learning method: Reading/visual Learning needs: None Barriers to learning: None Additions/Comments: Patient states that she does not study as much anymore, but occasionally still attends some courses that she might need to develop her business. The patient still has the same study group from law school, and they meet once a week/every other week to keep educating each other and keep their education growing. Falls Risk (Morse Scale) 1. History of falling within the last three months? No = 0 Yes = 25 2. Secondary diagnosis? No = 0 Yes = 15 3. Ambulatory aid: Bedrest/nurse = 0 crutches/cane/walker=15 furniture=30 4. IV/saline lock? No = 0 Yes = 20 5. Gait/Transfers: immobile/nml/BR=0 weak = 10 impaired = 20 6. Mental status: oriented to own ability = 0 forgets limitations = 15 No Risk = 0 to 24 Low Risk = 25 to 50 High Risk = greater than or equal to 50 Patient Score: 0. Patient has no risk of falling. Comments if applicable: Patient appears stable, and in control of her gait.
Patient Score: 23. Patient is at low risk/no risk for developing a pressure sore/ulcer. Comments if applicable: None Summary of assessment findings: In summary, the patient is 53-year-old female who came in for her annual checkup. Patient seems in good overall health, with no new complains. Patient sees her dentist every 6 months and also goes for her mammograms every 6 months. Patient was diagnosed with hypertension, fibromyalgia, Gerd, allergy induced asthma and anxiety. Patient takes medication for all of these conditions and it is all well managed. Patient also has Vitamin D deficiency which she takes supplements for. Patient complains of pain associated in upper bilateral extremities associated with the fibromyalgia, and she takes medication for this. Patient also mentioned that she experiences some depression and anxiety which she thinks is “normal” and is as a result of taking care of her disabled daughter and her fibromyalgia. Patient is taking medication for this, and she states that her emotions and mental health is under control. Patient has allergies to penicillin and pine trees. Patient reported no use of tabaco and consumes 2/3 alcoholic beverages a month. Patient also denied any abuse of drugs.
Patient states that her sleep schedule is not ideal, and that she does not get enough sleep since she has to get up at night to assist her disabled daughter. Patient stated that she does not exercise a lot and did mention some weight gain. Patient does not have any learning, physical, or social barriers and she is capable of completing her daily tasks independently. Patient has a good family structure and extra help in taking care of her daughter. Patient stated that her only current stressors is running a business and taking care of her daughter along with dealing with the pandemic. Patient seemed alert during the entire checkup, she seemed in a good state of mind, with good hygiene, and she seemed well hydrated and well nourished. Patient did not have any follow up questions or any concerns. Identify 2 developmental theorists who apply to this patient, stage of development and one statement which made you decide this: • Erik Erikson Theory of Psychosocial Development: Developmental stage is stage 7. Generativity vs Stagnation. This stage take place during the middle adulthood (ages 40 to 65 yrs.). Since the patient is 53 years old this theory’s stage of development applies to her. This patient also has a supportive family and her own business, and, in this way, she is giving back to society. Through her successful business and supportive family, she develops a sense of the bigger picture through generativity. After her diagnosis she has started to feel unproductive and not as involved in her daily life as in the past. This might contribute to stagnation which individuals in this stage might experience. It is important for individuals like her to focus on the good and to make positive changes that will benefit themselves and others. • Abraham Maslow’s Hierarchy of needs: Tis hierarchy of needs is a motivational theory that comprise of a five-tier model of human needs, often depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards the needs are physiological (food and clothing), safety (job security), love and belonging needs (friendship, esteem (prestige and feeling of accomplishment), and self-actualization (Achieving one’s full potential, including creative activities). The needs lower down in the hierarchy must be satisfied before individuals can attend to needs higher up. This patient has move through all of the hierarchy needs since she has good physiological needs (house, food, clothing, drink – and everything she needs for survival). She also has her safety needs fulfilled (patient has a good job, and she also has medical care, emotional security, freedom, social stability, property, health, and wellbeing). The patient also has love and belongingness needs, since she has a good family support and structure, feeling of belongingness, friendships, intimacy, a business, love, and affection. The patient has esteem needs in which she has esteem for herself (dignity, achievement of running her own business, independence in which she can take care and provide for herself and family) and also the desire for reputation or respect from others (her status and her prestige and the respect from her employees). The patient also has self-actualization needs in which she knows her potential, her self-fulfillment and seeking personal growth (discover better ways to deal with the care of her daughter and improving her business) as well as peak experiences. In this stage the patient is doing everything she can to become the most successful that she can be in everything that she does. If all of these needs are satisfied, the individual can function optimally. This patient seems to have met all of these needs, and therefore she will be able to function optimally. • Kohlberg’s Theory of Moral Development: Level 3: Postconventional (maintaining internal principles of self), Stage 5 and 6. Stage 5: Orientation to social contract legalism: since the patient is an older adult she associates with this stage. The patient is also a lawyer, which associates a lot with this theory, seeing that it is a lot about accepting and following the rules and laws and respecting the rights of other individuals. The patient has to honor some of her clients and has the obligation to her clients to do defend them and do the right thing, even when others do not agree with her.
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