Comprehensive Health Assessment Paper Essay

The purpose of this paper is to discuss the results of a comprehensive health opinion on a patient role of my choosing. This comprehensive assessment let ind the patients assoil health history and a intellect-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a veritable source. Other sources of data, much(prenominal) as medical records, were non available at the time of the interview. Physical examination data was obtained through inspection, palpation, percussion, and auscultation techniques. The case national results atomic number 18 interpreted from the perspective of a registered nurse, and three nursing diagnoses argon identified.Biographic DataM. H. is a 63-year-old married white female. She is currently laid-off for four months. Her intimately novel employment of seven years was as a private place health aid for a booster units elderly parents who fool since passed away. She wa s born in Buffalo, New York into a family of German decent. She currently lives in a suburb of Buffalo, N. Y. English is her chief(a) language.Culture and SpiritualityM. H. was elevated in a traditional German family where her father was the head of the family unit. However, her father and mother made m whatever decisions inversely and shared household chores (Purnell, 2014). Her father was an Air Force pilot during domain War II, and consequently 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 evaluate to be polite, use table manners, be on-time to meals, respect their elders, do as they were told, share, finish their chores originally recreating, get good grades in school, pray before meals and at bedtime, and attend church e really Sunday and on consecrated days (Purnell, 2014). Past health HistoryWhen she was a child, M. H. did not guard some(pr enominal) 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 2 times for childbirth. Her obstetric history includes Gravida 2/ bound 2/Preterm 0/Abortion 0/Living 2. Both births were hick vaginal deliveries.Surgical history includes tubal ligation at age 24, and remotion of benign cysts in her left breast, left cheek, and left wrist surrounded by the years 1998-2003. All of her childhood vaccinations are up to interlocking. She gets vaccinated for influenza almost every year, but she did not get vaccinated this season. She receive the varicella zoster virus vaccine in February, 2015 no reactions noted. Her hold water tetanus shot was more 10 years ago. She denies ever having been open(a) to tuberculosis (TB), and nor has she ever had a TB skin test (Jarvis, 2012).M. H. sees her first-string atomic number 101 every year for a physical. Her ultimately physical was in February, 2014. She to a fault 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 knocker tests have never been ab familiar. 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 telling to allergies, M. H. has no k at a timen drug allergies. Current over-the-counter medications include an effortless 400-600 mg dose of ibuprofen for aches and pain s, 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 oncedaily for care link up dizziness, and a 20 mg tablet of Atorvastatin for high cholesterin. She drinks alcohol socially, approximately two 12 ounce beers a day. She is a former smoker of ane pack of cigarettes a day for nearly forty years. Her quite date was September, 2011. She denies the use of street drugs.Review of SystemsM. H. states that she is generally in good boilers suit health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems. No history of skin disease. tegument 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 l oss, tinnitus, or top. Nose and sinus history includes clear nasal discharge since last October, and casual nose bleeds states she use to get nose bleeds frequently 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, offer up 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 vessel refill less than 3 seconds. Heart rate is in normal sinus. Bowel sounds are present in all quadrants. Her psychosocial status is earmark. M. H. denies recent weight change, weakness, fever, sw eat, or fatigue (Jarvis, 2012). Abnormal findings include an elevated cholesterol level, which is also familial. Furthermore, she has a history of speech pattern related anxiety, and was diagnosed with anxiety related dizziness in 2012. She states that before she st arted taking a medication her restitute prescribed, her dizzy spells could happen at any time. As a result, she avoids accredited situations, such as riding in a boat.Functional mindAfter 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 wastaking care of her elderly mother, her mothers 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 store 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 prescribedly. She s tates that she is an h wizst, hard-working woman. She takes her mark for a walk several times a day for exercise, and is free lance 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 niggling bowl of whole grain cereal with skim milk or a protein shake for breakfast, soup and/or sandwich for lunch, and a rail of lean meat with a vegetable side for dinner. She and her husband at times order pizza, get a fish fry on Fridays during lent, or go out for Chinese food. Normal elimination pattern includes on e 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 husbands 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 notes to pay bills, repairing their old house, and being married andhaving a family.Conclusion found 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 precedence diagnosis is Anxiety (moderate) related to stress as manifested by insomnia and dizziness. gage antecedence 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).ReferencesDoenges, M. E., Moorhouse, M. F., & Murr, A. C . (2010). shields 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.