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NR 302 Health Assessment I Health History RUA paper

Demographic Data

L.S. is a 23-year-old Caucasian woman born in Baltimore, Maryland on February 4, 1993. Her primary language is English, and she has a basic understanding of Spanish. She completed high school in 2011 and currently resides in Salisbury, where she attends school while working as a veterinary receptionist/technician. Now, she lives with her boyfriend and his parents as she works towards saving enough money to move out independently. The patient reports experiencing frequent headaches.

Health Perception:

L.S. acknowledges that she is obese but mentions that she has been conscious of her eating habits and engaging in regular running sessions to prepare for an upcoming marathon. Despite considering herself overweight, she perceives her overall health to be good. She is highly focused on maintaining a healthy lifestyle in preparation for the marathon scheduled in a few months.

NR 302 Health Assessment I Health History RUA paper

Past Medical History

L.S. does not smoke but occasionally consumes alcoholic beverages on weekends when she is not working. She has never been hospitalized for any significant health issues. Still, she has previously been diagnosed with shin splints, a condition she experienced during her active participation in soccer during high school. When L.S. experiences headaches, she takes 200mg of Ibuprofen for relief.

Family History

Paternal grandparents are both alive and have completed high school. L.S.’s grandfather is a retired firefighter who was diagnosed with diabetes at the age of 73 and experienced a heart attack at 75. Her grandmother, who is also retired, underwent spinal surgery in 2015 but is otherwise in good health. Maternal grandparents are deceased, both high school graduates. L.S.’s grandmother had a history of poor circulation and smoked until 25. She passed away due to lung cancer. Her grandfather, a Navy Seaman, was a heavy drinker and died from bladder and prostate cancer. L.S.’s mother holds a Bachelor’s Degree and works as an IT Manager at the US Census Bureau with no significant health concerns. L.S. has one sibling, a brother, who had a heart attack at 41 and was later diagnosed with colon and liver cancer at 58. Her father holds a Bachelor’s Degree and works as an IT Specialist with the DOD. He has hypertension, obesity, pre-diabetes, migraines, and chronic sinusitis. L.S. has another sibling, a brother, who was diagnosed with type 2 diabetes.

NR 302 Health Assessment I Health History RUA paper

Review of Systems

The interview with the patient was both absorbing and insightful. We decided to meet at a local coffee shop, which created a relaxed and comfortable environment for our discussion. The patient seemed at ease, and their willingness to answer questions made the process smooth. I felt a slight nervousness initially, but my preparedness and utilization of the knowledge gained in class helped me navigate the interview effectively. Before diving into the interview questions, we conversed casually over a cup of coffee. This allowed us to establish a connection and build trust, which made the patient more open to sharing information. I was pleased to find that there were no significant barriers to communication, and the patient’s comfort level facilitated their willingness to disclose information. However, I recognize that establishing a trust may not always be as straightforward in future interactions, and I will be prepared to adapt accordingly.

While I gathered most of the necessary information from the patient, I realized that I relied on closed-ended questions more frequently than I intended. Moving forward, I aim to incorporate more open-ended questions to encourage deeper discussion and gain a better understanding of the patient’s experiences. Toward the end of the interview, I recommended that the patient seek additional information and educate themselves about the effects of diabetes and nutritional values. The patient expressed genuine interest in these topics, recognizing their potential impact on their future health. In retrospect, the interview with this patient provided valuable learning opportunities. It allowed me to apply the skills learned in health assessment and emphasized the importance of building trust, utilizing open-ended questions, and providing appropriate resources for patient education. The abnormalities noted during the review of systems, such as elevated blood pressure and skin issues, will be further evaluated and addressed as necessary.

NR 302 Health Assessment I Health History RUA paper

Reflection

The interview process with L.S. was engaging and enlightening. We chose a comfortable coffee shop as the location, which helped create a relaxed environment for the discussion. L.S. specifically selected this place because it was her favorite spot to study, allowing her to feel at ease and open to answering my questions. Initially, I felt a bit nervous, but I had prepared well by thoughtfully organizing my questions and applying what I had learned in class, which contributed to the smooth flow of the conversation.

Before diving into the interview, we chatted and got to know each other over a cup of coffee. This helped establish trust, as L.S. felt more comfortable sharing her information with me. It was fortunate that no barriers needed to be addressed during the interview, as L.S. trusted me from the beginning. However, trust may not always come as quickly in future interactions, and I need to be prepared for such situations. While I gathered most of the necessary information from L.S., I realized I relied on closed-ended questions more than I would have liked. In the future, I aim to ask more open-ended questions to encourage further elaboration and exploration of the patient’s experiences. After concluding the interview questions, I provided L.S. with recommendations to seek additional information and educate herself about the effects of diabetes and nutritional values. L.S. showed great interest in learning more about these topics, recognizing their potential relevance to her future health.

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