21 Nov NUR 315: Health Assessment for the Registered Nurs
NUR 315: Health Assessment for the Registered NurseHealth History AssignmentDate of Interview: 1/10/19Patient Information/Health HistorySex: q Male q Female q Other Age: __45____What does the person consider his/her primary health concerns? Interstitial cystitisDo these health concerns interfere with: q Work? q Sleep? q Leisure Activities?If yes, please explain: Intermittent pain and spasms. Time spent under heating blanket. Pain relievers. Bladder distension q 6 monthsList any current medical, behavioral, or mental disorders: GERD, Interstitial Cystitis (IC)List any other relevant past medical, behavioral, or mental disorders and dates:List the approximate dates and type of any past surgeries: Appendectomy (July 1999), C-section (Jan 2013)Does the person experience pain on a regular basis? YESIf yes, please describe the nature/type of pain and rate it on a scale of 1-10 (10 is most severe): “Pressure”, “Burning”Current dietary practices: Eats about 2 meals a dayCurrent sleep patterns (adequacy and amount): Poor sleep. 5-6 hours a nightDescribe past and current tobacco use: NoneDescribe past and current alcohol/drug use: Social less than 1 a monthDoes the person have any allergies? NSAIDSCan the person care for him/herself? If not, how is care managed? Person care for selfPsychosocial history (include occupation, education, family responsibilities, social support, religious preferences, cultural influences): Pt states she is a consultant. BA in criminal justice. Married with 1 daughter. Social support from husband. “in fight with her sister” Pt states she is Jewish and tries to attend services regularly. Pt has strong religious belirfsList all medications, dose, schedule, and reason for taking:Omeprazole 40 Mg daily for refluxUribel PRN for bladder spasmsHydrocodone 5/325 PRN for bladder painMVT DailyBirth Control Pills Daily Enter a 1 for a current problem and 2 for a past problemDescribe the items above as needed. Select one of the interviewee’s chief health concerns and use the OLD CART and ICE acronyms described in Lesson 1 to further evaluate it. Onset – Started at age 20Location -bladderDuration- ongoingCharacteristics- burning and stabbing painAggravating factors- high stressRelieving Factors- antispasmodics and heatTreatments- bladder distention. Has talked about Botox injections or having an Interstim placed Impact on activities of daily living- pt states no impact on daily life, other than when bladder distention is performedCoping Strategies- pt states she is trying meditation to deal with high stress situations. Learning deep breathing techniquesEmotional response- pt is tearful when going to have bladder distention and immediately after. Summary Based on your assessment, discuss key points related to the person’s overall knowledge of their health conditions. Pt seems very knowledgeable about their health condition. Still unsure if she wants to have Botox injections, fearful it will hurt or not work. Pt unsure if she wants the Intersim placed, afraid she will feel the “shock” What factors could impact this person’s ability to seek/receive follow up care (i.e. cost, lack of motivation, transportation etc.)? Patient also suffers from anxiety and depression so there is fear of the unknown. Pt seems to have memory issues, cannot remember what MD said about Botox or Interstim, requires husband to be at all important appointment to “help remember” Develop a plan of care. Identify a nursing diagnosis, measurable outcome, and nursing intervention related to a medical, behavioral, or mental health concern. The intervention should be one that you can implement and evaluate within the time frame of the class.
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