NAME CAITLIN MARTINEZ DATE OCTOBER 29", 2012 CALIFORNIA STATE UNIVERSITY, STANISLAUS SCHOOL OF NURSING 1N2000 - Health Assessment 1. Client Profite: Name-(Init City Tracy, CA. Birthdate 3-15-73, (Kee 39 Sex_Female_ Religion Reformant __ Birth Place Romania__¢_~ ‘Occupation RN. Ethnicity Hungarian Marital Status, Married Reliability and source of history Reliable Historian; Self TI. Cultural and language assessment: (Address 3 areas from the Cultural Assessment Guide in the Jensen Cultural Awareness chapter 11) (1Opts) + Affiliations: Patient self-identifies with being Hungarian; however, she says that she only identifies with them'To a certain degree. There are a lot of practices that she doesn't follow, For exaniple, after a woman gives birth to her baby, she is not allowed to take the child out of the house for 6 weeks- After the 6 weeks, the woman is supposed to go straight to the church to have the baby baptized and then she is allowed to take the baby out in “publie™. The patient says that she did not follow this practice at all; she took her daughter Julia out of the house without any restrictions. Patient was born in Romania and ‘moved to Tracy when she was 25 years old. She is an IN. at Sutter Alta Bates in ——~— Berkeley. «* Health-Related Beliefs/Practices: Patient says that her ideal body weight does not coincide with the ideal body weight of her culture. Many Hungarian women are overweight because of their nutrition and lifestyle practices. They eat a lot of bread, pork, fattening foods. and high calorie foods. Patient states that she believes that being healthy ts more ideal than just being thin. She makes healthy meals and likes to go on a walk every day. Patient also states that she uses some herbal remedies when she sick. Her grandmother told her that horseradish and honey or chamomile tea help to clear the sinuses and. aint tea elas relieve indigestion. Patient affiliates with the Reformant religion, but sa¥¥ that it doesn’t influence her views on health. She is a nurse and believes in healthcare, but personally does not like to take medications if it’s not completely fl « e necessary. She says that as Romania she would get sick often with common ( colds and they would always teat it withantbitics, so now her body dagen’ fight colds very well. (WH Mn FandinO thay petroces'* ‘¢ Nutrition: Patient explains that her culture has very unhealthy eating habits. They eat a lot of fattening, high caloric foods. She says that it doesn’t really influence her nutritional habits though; she likes to eat healthy. The patient explains that eating is atime to be social and spend time with your family. In her culture, everyone is supposed to sit down together for lunch and eat soup. The patient says ‘she tries to follow this tradition and that she likes fo eat with her daughter and her husband , when her husband isn’t at work.‘The patient says that she is normally the one who goes grocery shopping because she is, home the most. She is also the one who makes the meals because her husband works a lot. The patient says that she and her husband both try to abstain from drinking alcohol. ‘They only drink every once in a long time. oe see IIL. Chief Complaint (CC): (4 pts) IV. History of Present Illness (HPI): (Details of cc, health management of ec and factors that affected this illness-onset, duration, frequency, location, qualifying and quantifying data, associated manifestations, aggravating and relieving factors, prior treatment and effect-OLD CART). (10 pts) Chief Complaint: Dermatitis due to dandruff on head. Patient says this started about 5 years ago. She gets dry, laky skin on er head (andy ha lls ont her fae and irate he skin. It has been an intermittent problem, sometimes it goes away for a little while and then it comes back. She says her skin gets red, dry, itchy, and irritated. Some aggravating factors are stress, the ‘sun (it dries her skin out more) and some shampoos and conditioners (Suave, Pantene). Some relieving factors are Head & Shoulders shampoo/conditioner, deep conditioning treatments, lotion, and sunscreen. She puts lotion and sunscreen on her face daily. She says that she has sec: her doctor for it and that it is mainly stress-related. She rates this complaint a 6/10. goad op | N V. Past Health Status: (immunizations, injuries, hospitalizations, medications, previous studies, allergies, exposure). (20pts) 1. Medical Hiness: ‘a. Childhood Iliness: Circle those experienced; indicate any sequelae, treatment: 1) mumps, measles, chickenpox, rubella- For all of these the patient did not receive any treatment. She said her family made her stay at home in her room, isolated from everyone else until she was well. 2) whooping cough, diphtheria 3) rheumatic fever (Patient given antibiotics), strep throat (Patient given antibiotics), joint problems, glomerulonephritis, scarlet fever Se 4) congenital defect, heart murmur 5) renal disease, seizures 6) other: N/A b. Adult Iliness: Deseribe, including dates, treatment, sequelae, etc. Pent had shingle about 5 yg ago. She wan't given any teatment fr itand was in a lot of pain. She didn’t take any pain medication either. She said she just stayed home until she was well again. 2. Psychiatric Ines: Describe, including dates, treatment, sequelae, etc. Patient denies any psychiatric illnesses.1. Surgical Procedures: Include date, location, surgeon, purpose, complications, Patient states that she had an appendectomy when she was 16 years old. The procedure was done by her doctor in Romania; appendix was removed successfully with no complications. 2. Accidents/Trauma/Injuries: Patient denies any accidents or injuries. 3. Other Hospitalizations: Include date, location, M.D., purpose, complications. Patient states that when she was about 13 she was hospitalized in Romania for a foot problem. She was having severe pain in her feet becauise she has really high arches and was ‘growing really fast, While she was Thete the doctors discovered that she had rheumatic fever. ‘The rheumatic fever was treated with antibiotics and the foot pain was treated with a week of physical therapy. She didn't have any complications from either of the treatments. Gna Bee el on xl © - 4, Immunizations: Include dates, any reactions, date of last tetanus (within 10 years). ¢ Flu Shot- last month, no reaction. * Tetanus. 3 years ago, no reaction ‘* TB- she had the BCG vaccine when she was younger, so she tests positive for TB, but she had a chest x-ray last year. When she first started working as a nurse, the hospital made her get a TB shot and her entire arm swelled up and was extremely painful. ¢ Hepatitis B13 years ago, no reaction * MMR-last year, no reaction 5. Allergies: (Drugs, foods, fabries, animals, plants, dust). Use of sunscreen Patient has seasonal allergies every March and April. She treats it with Clar 6. Medications: (RX, herbal medicines and OTC). Include dosage and frequency taken for OTC, herbal medicine and RX. Patient denies taking any medications. 7. Exposure to environmental Hazard: eg. dusts, gases and vapors, chemicals, radiation, noise, heat, etc. exposure in the military Patient denies any exposure to environmental hazards that she knows of. 10. Blood Transfusion: Patient denies receiving a blood transfusion. a 11, Foreign Travel/Military History/Past ResiPatient lived in Romania for 25 years. She traveled a lot to Hungary, Austria, and Montenegro. VI. Personal Habits: diet, patterns of work-sleep-exercise-relaxation, use of tobacco (pack- years), second-hand smoke exposure, alcohol, coffee, tea and recreational drugs. (10 pts) jet: Patient eats 3 meals a day with snacking in between. She believes that breakfast is very important. She usually eats fruit and cereal for breakfast, for lunch she tries to eat soup because that is the tradition of her culture, and for dinner she makes a variety of different foods (usually some type of meat, vegetables, and a salad). Patterns of work-sleep-exercise-relaxation: Patient works 2-3 12-hour shifts a week. She says that she likes to have at least 8 hours of sk night. She explains that she functions best when she’s had at least ® hours of sleep. She says that she is always moving around and doing things with her 5 year old ‘laughter They ike po on Bike rides or on walks. Patient expl ‘that she doesn’t have a whole lot of time to just relax, but when she does she likes to read, or sometimes watch T.V. Tobacco, 2™ hand smoke, alcohol: Patient used to smoke cigarettes for about 5-7 years, but does not smoke anymore. She was exposed to second hand smoke as a child because her grandfather smoked around her. She says that she almost never drinks alcohol; every once in a long time she will have a glass of wine. Coffee/tea: Patient drinks a cup and a half of coffee every day. Gpab j ab Recreational drugs: Patient denies ever using recreational drugs. VIL. Psychosocial History/Personal Profile: (organized nursing assessment of family and li situation, routine of daily living, stresses, reactions to illness, coping mechanisms, and relationships with others, etc.) (10 pts) Family/living situation: Patient and daughter. es in a three bedroom house in Tracy, CA with her husband, Daily routines: On a typical day, the patient says she wakes up at 0700, gets her daughter ready for school, eats breakfast, drops her" daughter off at school, gets groceries, cleans her house, runs errands, picks her daughter up from school, eats lunch, taker her daughter to agymnastics/soccer/gil scouts, eats dinner at 1700, gets her daughter ready for bed, has reading ‘time at 1900, and goes to sleep around 2000-2030. Stresses: Patient explains that she has a lot of stresses in her life right now. Her husband had a pulmonary embolism just a few weeks ago, her dog got ran over by aca a week before that, and she has another strike at work on November I*Reactions to illness: Patient says when she gets ill, she takes time off of work and relaxes at home. She eats soup, stays in bed, and lets the illness run its course. Coping mechanisms: Patient says that time heals everything and that talking things that are bothering her out with her husband always helps. Relationships with others: Patient says that she has great relationships with other people. She has a wonderful relationship with her husband and her daughter. She had many good friends. She keeps in touch with her ftiends and her family via Skype and phone calls. Her family stays in the USS. for 6 months out of the year and then goes to Romania for the other 6 months VILL Family History: (familial, inherited or contagious diseases). Include Note relationship, age, illnesses, age of death if not living. Diagram a Genogram (refer to chapter 3 for assistance) (10 pts) Mother of Mother Of EV. Deceased at age 72 Died tom massive ‘heart attack Hear Disease Father of Mother of EV. Deceased at age 75 Diedtom stroke Diabetes Died tromheart attack Hoar Disease Mother of E.V. ‘agesss Adtis HeartDisease Father of EV. ‘Ages69 asihma atin Father of Father of EV. Deceased at age 78 Died ttom stroke EV. Age: 39 ‘Seasonal AllergiesIX. Review of Systems: Presence or Absence; if present, describe. (20 pts) 1 General: Patient is dressed appropriately, well-groomed, and answers questions appropriately. She believes that she is in good health, height: 5°7” weight: Present 130 Highest 145 (pregnant) Lowest 124 (-)weight change (recent) (fever, chills, sweats (weakness, fatigue (insomnia, nightmares (2)functional impairment: 1 = full self-care 2= use of equipment 3 = requires assistance or supervision 4=help from people and/or equipment 5 = fully dependent Refer to Functional Health Assessment pg. 44-46 (BOX 3.1) 2. ‘Skin/Hair/Nails: (Erythema (redness of skin), jaundice Ceyanosis, pallor lesions, pruritus, rashes: Patient has dermatitis and small nevi on face (+)sunsensitivity: Patient says her dermatitis is sensitive to the sun; she uses sunscreen, daily aa (nails, hair: Nails are normal, but hair id dry and has dandruff on scalp (past skin diseases (self-care other 3: Head: (Headache: Patient has headaches once in a while and when she doesn’t drinkcoffee (Dizziness, lumps or swelling a (-)trauma_ | (jother Face: involuntary movements, edema, masses or lesions No involuntary movements, no edema, no masses, small nevi on face 4 Eyes: Last eye exam (date) Last summer. ‘refractive error, glasses/contact lenses; vision (20/20) (pain, photophobia(intolerance of light), excessive tearing (glaucoma, cataracts (jinflammation, redness (enucleation (otherBars Qearache, infection (deafness, diminished hearing (hearing aid (discharge, itching (trauma ©xinnitus (vertigo Oother Nose/Sinus’ oF (QEnistaxis (nosebleeds) (discharge, stuffiness: Patient has seasonal allergies that cause stuffiness (frequent colds, sinusitis, hay fever: Patient gets frequent colds, sinus infections, and bas seasonal allergies. She takes Flonase to reduce the inflammation in her nose and sometimes take antibiotics for the sinus infections (obstruction, polyps (change in sense of smelt (trauma (+)pain, swelling, heat: Swelling occurs with her seasonal allergies and sinus infections (other Mouth/Throat: Last dental exam June 2012 (caries, extractions, dentures: Doesn’t currently have any, but used to get a lot of cavities as a child; toothpaste in Romania wasn’t very effective (bleeding tender gums, pyorrhea (purulent inflamm. of gums) ()soreness of mouth, tongue (idryness or excessive salivation (Odysphagia (sore throat ()post-nasal drainage: Occurs with allergies (voice changes (change in sense of taste ()self-care (other (Olimited motion pain Omasses other Breasts: (self-examination: Patient says she performs SBEs, but not as regularly as she should (lumps:(pain, tenderness Chipple discharge, bleeding (change in appearance (other Pulmonary: Last chest x-ray February 2012 Result Negative ‘TB skin test N/A. Result N/A (ough (sputum (shortness of breath (wheezing, asthma ‘(hemoptysis (Cpleurisy/chest pain (tuberculosis (Cyrecurrent respiratory infections (pneumonia, bronchitis (emphysema Qother Cardiovascular: EKG Date N/A. Result N/A (chest pain/discomfort (SOB (orthopnea (dizziness, syncope (Qedema (©palpitations ‘Ceyanosis (hypertension (heart disease, murmurs (coldness, numbness, discoloration of extremities (varicosities (Oclaudication/cramps (thrombophlebitis (headaches (self-care (other astrointestinal: \change in appetite, obesity, disorders of nutrition ()indigestion, heart burn, food intolerance: Gets indigestion related to stress; diagnosed with GERD; spicy foods aggravate it; eats crackers to alleviate it _ (flatulence, eruetation (nausea and vomiting13, (hematemesis (appendicitis (bowel habits: Has a bowel movement everyday Omelena (black, tarry stool) (-idiarthea/constipation (rectal pain, bleeding, hemorthoids (abdominal pain (abdominal mass, hernia (hepatitis, peptic ulcer, pancreatitis, gallbladder disease other Genitourinary: (frequency (include volume) : Urinates multiple times throughout the day, “normal. volume” a (nocturia polyuria, oliguria (-)dysuria, urgency (hematuria (-jincontinence, dribbling (hesitancy @abnormal odor or color (-)pyuria, urethral discharge (*yrenal colic pain, stones: Patient had kidney stones a few years ago; no treatment (pain: suprapubic, lumbosacral, perineal (urinary tract infections (sexually transmitted disease (self-care (other Male (Not applicable) testicular "self-exam" prostatic disease penile discharge, lesion testicular mass, pain sexual activity/orientation, contraception, concerns other Female Last pap smear Last vear Results Normal Last mammogram N/A LMP _10-13-2012 Age of menarche 13 _ Age of menopause_N/A. Gravida (# of times prez_2__ Para (# of births) _1 Abortions_1_Premi_0_ Stillbirth _0 Ectopic _0,14, 15, 16. (Course of preganancy, length of pregnancy, length of labor, baby's weight and sex, type of delivery) Patient says she had a very good pregnancy when she was pregnant with her daughter. Het pregnancy lasted for 37 weeks and 23 days. Her water broke on a Monday afternoon at work and on Wednesday at 3 o'clock she had to be induced because she wasn’t having regular contractions. She received an epidural that Wednesday morning and pushed for 3 hours. Her daughter weighed 6 Ibs. 3 02. and the patient had her vaginally. contraceptive usage - specify (#)dysmenortheal (cramping): Patient has a little bit of cramping while on her period ()menorrhagia (excessive bleeding), metrorrhagia (vaginal discharge, pruritus (dyspareunia, pelvie pain (post-coital bleeding (post-menopausal bleeding ‘(Q)sexual activity/orientation, concerns other ‘Musculoskeletal/Back and Extremi (backache (joint pain, arthritis, gout ()stiffness, decreased ROM (joint swelling/deformity (muscle weakness, pain (Qother Neurological/Psychiatrie: Oseizures, twitching, tremor (loss of consciousness, syncope paralysis, weakness (sensory change, numbness, tingling (change in coordination, gait disturbance (*)change in mood or thought processes, memory: Patient gets moody while on her period —— (anxiety, depression (if positive re: suicidal ideation) (attention span: Patient says she feels like sometimes she has a short attention span (other Hematopoietic/Lymph: (Qanemia (bruising, bleeding tendency: Patient says she bruises really easily (blood dyscrasia (diseased blood) (adenopathy (enlarged lymph nodes)Qother 17. Endocrine (-)temperature intolerance ‘(Qgoiter, other thyroid malfunction ‘(Chdisturbed growth and development (Cdiabetes (hormone therapy (change in secondary sex characteristics (Qother 18. List one actual nursing diagnosis and one priority mursing intervention. One nursing diagnosis for this patient is impaired skin integrity related to her dermatitis. One priority nursing intervention is to encourage the patient to adopt skin care routines to decrease skin irritation (bathe in lukewarm water, pat area dry, apply topical creams, etc.). f 19, What were the three most important things you learned from this assignment? From this assignment I leamed how to interview and communicate with patients. This assignment allowed me to sit down with someone that I don’t know very well and leam about, their health history though asking questions and-making them feel comfortable talking to me about their personal life. I also learned a lot about the Hungarian culture. Before I did this f assignment I didn’t know anything about this culture and now I know quite a bit. And lastly 1 learned how culture affects every aspect of a person’s life. In different cultures people believe in different things, cat different foods, take different medications, etc. It's important to ask questions about a person’s culture and learn about it so that you can understand their health habits and their lifestyle. ge sayonel