Posted: April 3rd, 2022

Case Study: Health History Assessment

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Introduction

In response to (D’Amico, 2011), well being Assessment to be a affected person means the systematic approach of gathering shopper’s information, with an intention of figuring out his/her present well being standing, the well being threat they could be uncovered to, and figuring out the well being apply actions to be achieved to enhance the affected person’s well being standing. It could additionally discuss with the intentional and interactive course of by which nurses critically gather, and analyses and digests the related collected data type the affected person to guage their the standing of their well being. On this essay, I shall current a well being historical past Assessment on an outdated aged affected person and subsequently there would be the have to make use of Complete Health Assessment (CAH), which is a scientific apply related for the aged sufferers. (Agedcare, 2013), states that the aged are uncovered to extra delicate medical and social points by way of the care necessities, subsequently requires Complete Health Assessment, that ensures expert employees that may guarantee care to the affected person. My affected person was aged Ms. Pamela Jackson, and subsequently, for the Assessment, I used to be fascinated with demographic information, the affected person’s notion on well being, previous medical historical past, each for the affected person and the lineage household, and another details about the affected person.

Demographic Information

The demographic information in an Assessment embrace the beginning yr, the gender, nation they arrive from and if there are, many ethnic teams then which one does the affected person belong. Ms. P.Ok was 86 years outdated by final yr once I assessed her. She is at present residing in New York however she was born in South Carolina. Pamela lives in third ground, on a narrative constructing however used an elevator, in a one-bedroomed home, and her kids helps her monetary, whereas for social safety and Medicare she receives type the federal government.

Notion of Health

World Health Group (WHO) (2014) defines well being because the state of being mentally, bodily, and socially nicely and it isn’t merely the thought of not having any illness. On this case, the aged normally don’t really feel comfy as they really feel lonely, with no one with them to Help them undergo. The affected person describes the ache that she goes via when the chest ache begins and hopes that issues may have been totally different if she have been wholesome. The affected person loves different actions, and usually nonetheless robust when she feels wholesome. She may go to the farm, stroll her canine round and after these actions she may calm down. Pamela normally feels that the chest pains and these sicknesses usually takes this enjoyable away from her, and normally really feel dangerous about it. She sometimes feels that she is already outdated and subsequently, she doesn’t need to undergo that approach as an alternative she will die. Feeling of social disconnectedness from the opposite members of the family who she can not go to usually, nevertheless, someday they make really feel wholesome and beloved. Subsequently, Pamela says that these days she loves her life and has a change of notion in direction of being wholesome.

Previous Medical History

In 1964, she had some surgical procedures achieved on her, the primary one concerned, whole belly hysterectomy that included the elimination of uterus together with the cervix, this surgical procedure is finished for girls via their vaginas when they’re confronted with circumstances such endometrial hyperplasia, uterine prolapse, or cervical dysplasia. This was extremely related for Pamela as a result of she was affected by dysplasia. 5 years later, she had one other surgical procedure, bunionectomy. This sort of surgical procedure helps within the elimination of bunion, which is an enlargement skilled on the joint base of a giant toe and it’s usually comprised of the mushy tissue and the bone. Pamela was experiencing irritation on her legs by then, and he or she had no becoming shoe, subsequently had undergo with surgical procedure (Bunionectomy, 2000).

The identical yr that she had bunionectomy, is identical yr that she was identified with hypertension, and this was the time her issues began. She was administered some medicine that at present she keep in mind which of them, however she will take into consideration is that she stopped utilizing them after three months as a result of that they had a aspect impact on her physique, as they have been inflicting drowsiness to her. Some years later, she was identified with peptic ulcer illness, however for this she was administered particular medicine, and that’s, cimetidine that helped her resolve the issue inside four months’ time. Pamela doesn’t have historical past of different sicknesses corresponding to coronary heart illness, lung illness, nor most cancers.

She had allergic reactions when she was administered penicillin again in 1965; the medicine triggered rashes on her physique and hives. Subsequently, she is often suggested to not use penicillin or for use on her by every other medical specialist. She even have a social historical past of utilizing alcohol, she has two beers each weekend with some wines when having dinner. She had no prescription for unlawful drug use, as she by no means used tobacco associated medicine.

Household Medical History

Pamela didn’t have the possibility to develop up within the care of her mom as she died on the age of 40, leaving Pamela very younger, that her aunt determined to take of her till she grew outdated. The reason for loss of life for her mom was kidney failure. Her father can be deceased, and the reason for his loss of life was a coronary heart assault, that stroke him and he was gone. Pamela has been feeling that alone as her husband died too, he suffered from pneumonia and seizures. The outdated girl doesn’t have any sisters, however was blessed with 4 daughters who’re all nicely, however the son additionally died and was affected by pneumonia. Her household subsequently has a historical past of hypertension however no diabetes or most cancers. Her members of the family wouldn’t have any behavior of alcohol use or people who smoke solely use alcohol throughout events.

Assessment of Methods

Ranging from the highest of her physique to the underside, she was interviewed on how she feels about each half. The usual physique vitality of the physique ought to good, the burden secure at 160 Ibs, and the usual peak 5’eight”2. Given the age of the affected person, her eyesight started to be blurry and this required her to put on studying glasses, however she has no diplopia or every other eye ache. The age Pamela makes her earing capabilities decreased, and subsequently, for therefore a few years, she has been experiencing listening to loss, therefore she has to make use of listening to support. Nostril: she has no historical past of tonsillectomy, and has been carrying full set of dentures for a few years and it has been working nicely for her, she has had no obstruction. She has no historical past of pleurisy, bronchial asthma, or coughing in her respiratory techniques.

By 1960, she was admitted of hematemesis and melena, which suggests vomiting of blood and discharge of black stool with blood (Wilson, 1990). Her endoscopy confirmed some proof of gastritis and subsequently obtained items of packed cells; this helped make her stool brown. Pamela has had a historical past of cystitis, E Coli, however was handled utilizing Bactrim. She had 5 pregnancies, with 4 profitable and one miscarriage had her menopause on the age of 50. By way of neuromuscular half, she skilled osteoarthritis on the shoulder, hips, and all of her knees for no less than 20 years. Pamela didn’t have histories of tension and emotional misery, despair, no blood clotting.

Developmental Concerns

In response to (Hoffman, 2001), improvement is a element within the healthcare throughout all of the lifespan; subsequently this provides benefit to the healthcare professionals to handle their purchasers. Erickson states that in every stage of improvement there are totally different duties that ought to be thought of and this be certain that a person experiences a normalized psychological improvement. The eight phases, on condition that Pamela is over 65 in age, she belongs to Ego Integrity vs. Despair.

By way of bodily improvement, there may be elevated vulnerability to ailments, and this led to the affected person experiencing many sicknesses corresponding to chest ache and aching joints throughout. The aged usually expertise modifications corresponding to integumentary together with sagging, wrinkling; musculoskeletal modifications together with lack of elasticity within the joints; metabolic price declines and different modifications that usually scale back the delight and ego of the aged. Subsequently, they often really feel deprived by their age.

The affected person had retired way back and subsequently has the problem of feeling despair, as he lived in a room alone, with the bodily challenges she may transfer round as she used to when she was younger. There may be decreased revenue for the shopper as she had retired. Lastly Pamela has lived for; lengthy and subsequently have gone via unhappy interval when the members of the family dies and stay her nonetheless alive.

Cultural Concerns

The affected person is an American belonging to the Caucasian ethnic group. She has lived in the US complete her life with none histories of migration to different nations. She resides in New York and fluent English speaker. She loves to look at motion pictures and take heed to some old style music with a view to keep away from having extra coronary heart assaults as a consequence of her standing. She is a retired nurse, with low-income sources and is dependent upon the federal government for social safety and Medicare, and a Christian who doesn’t have plenty of cultural consideration and subsequently, offers a straightforward time to the healthcare professionals.

Psychosocial Concerns

Pamela understands her scenario however the perfect factor is that she lives with one among her daughters to Help her undergo the experiences. Nevertheless, the affected person is a really lively persona; that is although she has the arthritic signs. She acknowledges and already accepts the center assault she usually have, however generally this makes her very anxious as she retains on questioning the second it is going to strike her once more.

Bodily Assessment

As a result of her mixture of chest pains and the center assaults, I’d critically assess her coronary heart functioning and the lungs too. There ought to be a cautious monitoring of the growing chest pains and coronary heart assault, this can be a proof of myocardial infarction and subsequently ought to be admitted for extra checkups. The affected person’s ldl cholesterol also needs to be monitored and subsequently ought to be suggested to have sufficient bodily workouts however mild ones, to make sure free-flowing blood circulation. Some medicines corresponding to HMG Co-reductase ought to be administered to scale back the ldl cholesterol degree within the physique.

Want Priorities for the Affected person

There are various aged particular person on the planet who’re confronted with such challenges of coronary heart assault and have chest ache as they proceed to get older. To prioritize the wants, there ought to be Assessment and screenings of the center capabilities of those individuals, and a few schooling that’s associated to the hypertension in outdated age and the way they’ll undergo the matter. The one troublesome half right here is the information that some kinds of meals that they should keep away from, such because the fatty meals. They need to be consuming principally greens with decreased sugary contents and a few workouts.

Collaborative Recourses

The primary collaborative useful resource for the affected person can be church, the place she may meet different family and friends and really feel beloved and cared for. Subsequently, she won’t should really feel lonely in the home and alone too. The following useful resource is the members of the family like her daughter and grandchildren coming over to present her a go to on the house. Doing a little, workouts might be one other useful resource serving to her to extend the center beat and circulation of blood.

Reflection

The interview happened within the room of the interviewee, I ensured that her daughter was not round in order that we may have free setting for her to reveal all the things to me. I first assured her of confidence with the knowledge and that it will Help to enhance the healthcare of the aged as she is. The stress between us decreased the extra I used to be asking questions, subsequently we may talk freely.

Throughout my time with Pamela, it helped learn the way vital well being Assessment was to the sufferers, principally to the fragile aged, who normally really feel exclude in most societies. I discovered the well being dangers that the aged undergo and might now have suggestions on find out how to clear up their issues. Among the obstacles I had have been the issue of insecurity with the knowledge, in a approach the interviewee at occasions didn’t present all the knowledge related for this Assessment. Nevertheless, the extra Question Assignment she developed the arrogance and was in a position to open up.

References

Agedcare. (2013, October). Complete well being Assessment of the Older Individual. Retrieved from Division of Health: http://health.vic.gov.au/agedcare/publications/assess/downloads/cha_summary.pdf

Bunionectomy. (2000). Retrieved from Encyclopedia of Surgical procedure: https://homeworkacetutors.com//write-my-paper/surgeryencyclopedia.com/A-Ce/Bunionectomy.html

D’Amico, D. a. (2011). Cilinical Pocket Information for Health an Bodily Assessment . Nursing Creator Donita D’Amico, 36-38.

Hoffman. (2001, January). AGE-SPECIFIC COMPETENCY. Retrieved from EIRCKSON’S DEVELOPMENTAL TASKS: https://homeworkacetutors.com//write-my-paper/au.af.mil/au/awc/awcgate/army/erickson_stages.htm

Wilson, D. (1990). Hematemesis, Melena, and Hematochezia. Retrieved from NCBI: https://homeworkacetutors.com//write-my-paper/ncbi.nlm.nih.gov/books/NBK411/