The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient’s complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained through inspection, palpation, percussion, and auscultation techniques. The case study results are interpreted from the perspective of a registered nurse, and three nursing diagnoses are identified.
M. H. is a 63-year-old married white female. She is currently unemployed for four months. Her most recent employment of seven years was as a private home health aid for a friend’s elderly parents who have since passed away. She was born in Buffalo, New York into a family of German decent. She currently lives in a suburb of Buffalo, N. Y. English is her primary language.
Culture and Spirituality
M. H. was raised in a traditional German family where her father was the head of the household. However, her father and mother made many decisions mutually and shared household chores (Purnell, 2014). Her father was an Air Force pilot during World War II, and then worked as a chemical engineer until retirement. The household atmosphere was loving and respectful. She and her five siblings were brought up as Roman Catholics. They were expected to be polite, use table manners, be on-time to meals, respect their elders, do as they were told, share, finish their chores before recreating, get good grades in school, pray before meals and at bedtime, and attend church every Sunday and on holy days (Purnell, 2014)
. Past Health History
When she was a child, M. H. did not have any serious illness, nor does she have any chronic illnesses currently. She did, however, have a severe case of chickenpox when she was about 3-years-old, and shingles about 18 years ago. M. H. has not been in any major accidents or had any life-threatening injuries during her life. She has been hospitalized two times for childbirth. Her obstetric history includes Gravida 2/Term 2/Preterm 0/Abortion 0/Living 2. Both births were uncomplicated vaginal deliveries.
Surgical history includes tubal ligation at age 24, and removal of benign cysts in her left breast, left cheek, and left wrist between the years 1998-2003. All of her childhood vaccinations are up to date. She gets vaccinated for influenza almost every year, but she did not get vaccinated this season. She received the varicella zoster virus vaccine in February, 2015; no reactions noted. Her last tetanus shot was more 10 years ago. She denies ever having been exposed to tuberculosis (TB), and nor has she ever had a TB skin test (Jarvis, 2012).
M. H. sees her primary physician every year for a physical. Her last physical was in February, 2014. She also sees her dentist annually for a check-up and cleaning. She is currently scheduled for April, 2015. As a child she never needed corrective lenses, but for the last 15 years she has needed glasses for reading. Therefore, her vision is checked annually, most recent appointment having been in January, 2015. Because she has a history of benign cysts in her breast tissue, she gets a mammogram every five years. Her last mammogram was in 2010. Results of her Pap tests have never been abnormal. She cannot recall the date of her last gynecological exam. She also gets a coloscopy every couple of years, since her father died of colon cancer.
In relation to allergies, M. H. has no known drug allergies. Current over-the-counter medications include an occasional 400-600 mg dose of ibuprofen for “aches and pains”, a daily vitamin, and melatonin for insomnia, and antacids, such as Tums, for her “heartburn”. Her current prescription medications include a 225 mg tablet of Venlafaxine HCL once daily for anxiety related dizziness, and a 20 mg tablet of Atorvastatin for high cholesterol. She drinks alcohol socially, approximately two 12 ounce beers a day. She is a former smoker of one pack of cigarettes a day for nearly forty years. Her quite date was September, 2011. She denies the use of street drugs.
Review of Systems
M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems. No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling, tender nodes, and goiter; full range of motion.
M.H. states that she performs self breast exams routinely and denies any lumps or discharge. Lungs are clear; peripheral pulses present bilaterally; capillary refill less than 3 seconds. Heart rate is in normal sinus. Bowel sounds are present in all quadrants. Her psychosocial status is appropriate. M. H. denies recent weight change, weakness, fever, sweats, or fatigue (Jarvis, 2012). Abnormal findings include an elevated cholesterol level, which is also familial. Furthermore, she has a history of stress related anxiety, and was diagnosed with anxiety related dizziness in 2012. She states that before she started taking a medication her doctor prescribed, her dizzy spells could happen at any time. As a result, she avoids certain situations, such as riding in a boat.
After graduating from Bryant and Stratton business school in her early twenties, M. H. spent 15 years as a manager of several apartment complexes. She then worked as a manager of a retail mini-mart for the next 15 years until she got layed-off. Meanwhile, with the help of her siblings, she was taking care of her elderly mother, her mother’s husband, and elderly mother-in-law until they all passed away. Shortly after these events, friends hired her to care for their parents, and now they have passed away. However, she still helps the friends by cleaning their house, completing simple home improvement tasks, and going grocery shopping and ruuning errands for them.
M. H. lives with her husband of 42 years. She was raised Roman Catholic, believes in God, but does not attend church regularly. She states that she is an honest, hard-working woman. She takes her dog for a walk several times a day for exercise, and is independent in her activities of daily living. She and her husband enjoy time with family and friends, and host dinners and get-togethers often. Her hobbies include sewing, upholstery, and gardening. Getting 6-8 hours sleep at night is M. H.’s normal pattern, although she has occasional stress-related insomnia.
She states she tries to eat healthy, is aware of “good” versus “bad” food choices, and does not have any food intolerances. Both her husband and she share the cooking and grocery shopping duties (Jarvis, 2014). A typical daily diet includes a small bowl of whole grain cereal with skim milk or a protein shake for breakfast, soup and/or sandwich for lunch, and a cut of lean meat with a vegetable side for dinner. She and her husband occasionally order pizza, get a fish fry on Fridays during lent, or go out for Chinese food. Normal elimination pattern includes one or two bowel movements a day; she has no problems urinating, although if she drinks regular coffee, it will cause urinary frequency.
In regards to interpersonal relationships, she has a very strong relationship with her siblings and their families, her husband’s family, and her children and their families. She enjoys caring for her grandchildren on an “as needed” basis. She qualifies time spent alone as productive and/or relaxing, stating “everyone needs a little time alone to work on their own projects” (Jarvis, 2014). She considers her neighborhood, house, and work environment safe. She states she has the “typical stresses of life, like making money to pay bills, repairing their old house, and being married and having a family”.
Based on the results of the comprehensive assessment data, M. H. is a relatively healthy person, who has not had any serious or life-threatening medical problems during her life. She presents with anxiety and anxiety related dizziness that is currently under control with medication. She follows up with her physician and other health care professions on a regular basis, eats healthy, and takes her medications as prescribed. She also has a healthy psychosocial status with family and friends.
From a nursing perspective, three nursing diagnoses apply to M. H. in her current situation. The first priority diagnosis is Anxiety (moderate) related to stress as manifested by insomnia and dizziness. Second priority diagnosis is deficient Knowledge related to anxiety and dizziness as manifested by M. H. stating lack of complete understanding of the condition. The third priority diagnosis is disturbed Sensory Perception (kinesthetic) related to psychological stress as manifested by sensory distortions (i.e., dizziness). These diagnoses will assist nurses to identify appropriate interventions that will help M. H. achieve an optimal state of wellness (Doenges, Moorhouse, & Murr, 2010).
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nurse’s pocket guide: Diagnoses, Prioritized Interventions, and Rationales (12th ed.). Philadelphia, PA: F. A. Davis Company. Jarvis, C. (2012). Physical Examination and Health Assessment (6th ed.). St. Louis, MO: Elsevier. Purnell, L. D. (2014). Culturally Competent Health Care (3rd ed.). Philadelphia, PA: F. A. Davis Company.
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