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NR 302 RUA Health Assessment

Health History Assessment

The individual chosen for the health assessment is AH, a 63-year-old Caucasian female who resides alone in a rural area but has close family support. AH’s perception of health is defined by being in good health, engaging in regular exercise, and consuming nutritious food. She considers herself to be between healthy and unhealthy as she experiences some health issues. AH, practices once a week and maintains a primarily healthy diet but wishes to improve her overall health and increase her exercise routine.

AH’s medical history includes degenerative disc disease, high blood pressure, hyperkinemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis. She has undergone neck and back surgeries, gallbladder removal, cataract removal, and hysterectomy. Her daily medication regimen includes a Spiriva inhaler, Allegra, Valium, Zoloft, gabapentin, Lopressor, and Protonix. Regarding family medical history, both AH’s parents had high blood pressure, which likely contributed to her high blood pressure. Her mother had asthma, increasing AH’s predisposition to the condition. AH’s father developed lung cancer from smoking cigarettes, and her mother dealt with anemia, necessitating multiple blood transfusions.

NR 302 RUA Health Assessment

Review of Systems

AH’s skin issues are limited to eczema, while her hair has some grey strands, and her nails appear normal. She does not experience headaches, head injuries, or dizziness. However, she has neck pain when turning her head to the right. There are no reported lymphatic issues. AH has decreased vision due to cataracts and wears eyeglasses. She underwent cataract removal surgery in June 2015. AH has no earaches or infections, and her hearing is good. Allergies to pollen and dust are present, but no significant sinus problems exist. Her mouth and throat appear healthy without pain, sore throat, toothaches, or lesions. AH manages asthma and emphysema, which occasionally cause shortness of breath. Despite her respiratory challenges, she can self-care, cook, and clean. Her only cardiovascular concern is high blood pressure, which she manages through medication and controlling her salt intake.

Developmental Considerations

AH has been dealing with asthma since childhood, which significantly impacted her life. Due to her condition, she faced limitations in participating in sports and prolonged physical activities, which affected her ability to play with friends. This resulted in fewer social interactions and challenges with weight management. AH has always attributed her weight struggles to her asthma.

NR 302 RUA Health Assessment

Cultural Considerations

During her upbringing, AH was intensely interested in attending church and exploring her faith. However, her family did not share the same level of religious devotion. This created a challenging dynamic for AH, as her father often made discouraging remarks about her desire to study the Bible and engage in religious activities. These negative comments made it difficult for her to fully embrace her religious beliefs and establish a meaningful connection to her faith community.

Psychosocial Considerations

AH experienced the loss of her husband nearly a year ago, which has significantly impacted her social life. She finds it challenging to engage in social events, as they remind her of the activities she used to enjoy with her late husband. Attending such events without him evokes feelings of sadness and longing. However, AH is fortunate to have supportive children who regularly visit her. At least one of her children sees her daily, and they try to have a weekly family night, providing AH with companionship and a sense of connection.

NR 302 RUA Health Assessment

Collaborative Resources

AH receives valuable support from her family, who visit her daily and accompany her to doctor appointments, ensuring she has assistance and companionship. Additionally, AH has found solace in a close-knit group of friends who share her religious beliefs. They attend church together every Sunday and enjoy post-service lunches, providing AH with a sense of community and shared spiritual experiences. Moreover, AH has developed a friendly relationship with her neighbor, who regularly walks for exercise several times a week, promoting physical well-being and fostering social connections.

Reflection

This interaction allowed me to apply the health assessment skills I have acquired. Given my familiarity with medical terminology and AH’s own experience with hospital visits, we were able to discuss her medical history effectively. However, I encountered some challenges regarding the review of systems, as AH had difficulty understanding specific questions. To address this, I took the time to explain each topic in a clear and accessible manner. Reflecting on this experience, I recognize the importance of considering cultural factors and should have probed further into any cultural issues that may have influenced AH’s health and healthcare experiences.

References

American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author. Jarvis, C., Tarlier, D., Pelt, L. V., Andrews, M. E., & Jarvis, C. (n.d.). Physical examination and health assessment (7th ed.).

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