NR 302 RUA Health Assessment

Student Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name

Date

Health History Assessment

The individual selected for this health assessment is SA, a 63-year-old Caucasian female living alone in a rural area, though she benefits from strong family support. SA defines health as a state of balance, achieved through regular physical activity and a nutritious diet. She perceives her health as moderate, citing ongoing health issues. Currently, SA engages in physical activity about once per week and follows a mostly healthy diet. She expresses a desire to improve her overall wellness by increasing the frequency and intensity of her exercise routine.

SA’s medical history is significant for multiple chronic conditions, including degenerative disc disease, hypertension, hyperkinemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis. She has undergone several surgeries, including neck and back procedures, gallbladder and cataract removal, and a hysterectomy. Her medications include Spiriva inhaler, Allegra, Valium, Zoloft, gabapentin, Lopressor, and Protonix. The family history shows a predisposition to hypertension, as both parents were affected. Additionally, SA’s mother had asthma, her father had lung cancer due to cigarette smoking, and her mother experienced anemia requiring multiple transfusions. These familial factors may influence SA’s current health conditions.

Review of Systems

SA’s skin, nails, and hair are largely normal, with the exception of eczema and some hair graying. She reports no headaches, head injuries, or dizziness, but experiences neck pain when turning her head to the right. Her vision is slightly impaired due to cataracts, for which she wears corrective glasses and underwent surgery in June 2015. Auditory health is intact, with no history of ear infections or hearing issues. Allergies to pollen and dust are present but do not cause severe sinus problems. Oral health is good, with no persistent sore throat, lesions, or dental pain. Respiratory conditions, including asthma and emphysema, cause occasional shortness of breath but do not significantly interfere with her daily activities. Hypertension is managed effectively through medication and dietary modifications.

Developmental Considerations

SA has lived with asthma since childhood, which has influenced her lifestyle significantly. Her respiratory limitations restricted her ability to participate in sports and extended physical activity, affecting her social interactions and contributing to challenges with weight management. SA associates her difficulties in controlling weight with her limited capacity for physical activity, stemming from her asthma.

Health Area	Assessment Findings	Developmental Impact
Health Perception	SA perceives health as a balance between exercise and nutrition and is motivated to improve her fitness.	Not applicable.
Medical History	Chronic conditions include degenerative disc disease, hypertension, COPD, asthma, emphysema, diverticulitis, osteoporosis; history of multiple surgeries.	Health issues limit exercise capacity and influence overall well-being.
Family Medical History	Both parents had hypertension; mother had asthma and anemia; father had lung cancer.	Increases predisposition to conditions like asthma and hypertension due to genetic and environmental influences.
Review of Systems	Minimal skin issues, normal auditory and oral health, occasional shortness of breath from asthma and emphysema, hypertension controlled with medication.	Childhood asthma influenced her ability to engage in physical and social activities, affecting weight management and social development.

Cultural and Psychosocial Considerations

SA’s upbringing included an interest in religion, particularly church participation and Bible study, although her family did not share the same level of devotion. Negative remarks from her father regarding her spiritual interests created a challenging environment, limiting her connection to her faith community. Psychosocially, the recent loss of her husband has significantly impacted SA’s social life, making social gatherings emotionally difficult. Despite this, her children provide regular support, with one visiting daily and weekly family nights helping to maintain a sense of companionship and emotional comfort.

Collaborative Resources and Reflection

SA benefits from strong family support, including assistance with medical appointments and regular visits. Community support is available through her religious friends, who participate in church and weekly social events with her. Additionally, a neighbor accompanies her on exercise walks, providing both social interaction and motivation for physical activity.

Reflecting on the assessment process, my skills in gathering medical history and lifestyle information were effective. Challenges arose in reviewing systems, as SA sometimes struggled to understand medical terminology. Simplifying questions improved comprehension. Future assessments could further explore cultural influences on SA’s health behaviors, providing deeper insight into her motivations and challenges.

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.).