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Health, Medicine, Nursing
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English (U.S.)
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Topic:
Comprehensive Health History Taking Nursing Assignment
Essay Instructions:
Select one patient (neighbor, family, or friend) and write-up their comprehensive health history. Include the following variables:
Identifying data.
Past medical history.
Health status, perceived barriers, and support.
Chief complaint (CC).
History of present illness (HPI).
Family and/or social history (PFSH).
Focused review of systems (ROS).
Identify age, spiritual values, and cultural variables that were considered and how these variables influenced your interviews or health history.
In a 1,000-1,250-word essay, summarize effective interview techniques for collecting a patient's health history. Include the following:
Address how to elicit the patient's interpretation of their health status, their perceived barriers, and support.
Critique the effectiveness of several history taking techniques with rationale from the readings.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is required.
You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.
Essay Sample Content Preview:
Comprehensive Health History Taking
Part I: Background
The chosen person is a friend and he is identified as Nikolai Ivanov, a 41 year-old Caucasian man. Upon interviewing his health history, he often experiences chest pains for the past year, which is his usual chief complaint (CC). Upon visiting his physician, it has been revealed that he is suffering from angina pectoris, which is a condition wherein the blood vessels that supplies oxygen and other blood products to the myocardium is impaired. Moreover, with his health status, Nikolai is at risk for developing myocardial infarction due to existing coronary artery disease as well as other cardiovascular diseases such as myocardial infarction and cerebrovascular accident. Perceived barriers are the limitations of sedentary lifestyle while he is supported by his family to boost his morale and the existing health care facility near the community to assist him with his treatment and maintenance of his health. History of present illness reveals that his temperature is normal at 36.6 degrees Celsius, pulse rate is 87, respiratory rate is 18, and blood pressure is at 110 over 70 mm Hg and ECG result of an elevated ST segment.
Nikolai’s father is also suffering from coronary artery disease such as angina, but was able to cope up through diet and exercise. His mother is diagnosed with high-blood pressure due to unstable blood pressure since she was 40 years-old. His grandfather from his mother’s side died of a heart attack fifteen years ago. Some of his relatives are also suffering from several heart ailments such as myocardial infarction, heart failure, and cerebrovascular accidents.
Social history involves his poor sedentary lifestyle, such as eating foods rich in fats, oil, and sugar in all of his diet without any control. He often likes sweet foods and usually eats junk food in between meals such as recess hours during the work. Nikolai is occasionally in a drinking spree for at least twice a week. He is also known to smoke at least 10 sticks of cigarette per day, but he can smoke at many as 1 pack of cigarettes containing 20 sticks or even more whenever he is on a drinking spree. As for the Review of Systems, the eye is normal with no signs of distress. Ears are normal. Swollen lymph glands are negative. His respiration is normal, but with a mild bacterial infection. Cardiovascular system reveals that he has angina. Gastrointestinal system is not in distress. Skin is pale with no signs of infections or allergies. He is mobile with no signs of musculoskeletal distress. He has normal reproductive and excretory without feeling any distress whenever he is going to the toilet and urinate.
Variables affecting Nikolai’s health
As for his age, Nikolai is 41 years-old and he is at that age where other people are also developing similar conditions such as angina or as worse as myocardial infarction. Age is a non-modifiable factor for individuals like Nikolai because it is a stage wherein the body starts to degenerate due to the loss of several hormones, tissues, and cellular components in the body. In this case, the body of patients like Nikolai can easily develop fatty deposits along the arterial walls of his coronary arteries and other parts of his circulatory system. At the age of 40, the fibrous component, elasticity, and the collagen of tissues, organs, and other structures across the body slowly degrade, allowing other invasive particles and microorganisms to settle.
The spiritual variable associated with Nikolai is that he is of the Roman Catholic denomination, which is his main religious affiliation. His divine perception is not as strong as that of other religious practitioners because he still believes that his lifestyle is more associated with the influence of his present history of medical illness. However, divine intervention is still significant to his physiological well-being. Seeking divine intervention allows his emotional stability to relax and feel the comfort of the environment. Through prayers, he believes that it plays an important role in stimulating his pituitary gland to release hormones that will dilate his cardiovascular structures such as the blood vess...
Part I: Background
The chosen person is a friend and he is identified as Nikolai Ivanov, a 41 year-old Caucasian man. Upon interviewing his health history, he often experiences chest pains for the past year, which is his usual chief complaint (CC). Upon visiting his physician, it has been revealed that he is suffering from angina pectoris, which is a condition wherein the blood vessels that supplies oxygen and other blood products to the myocardium is impaired. Moreover, with his health status, Nikolai is at risk for developing myocardial infarction due to existing coronary artery disease as well as other cardiovascular diseases such as myocardial infarction and cerebrovascular accident. Perceived barriers are the limitations of sedentary lifestyle while he is supported by his family to boost his morale and the existing health care facility near the community to assist him with his treatment and maintenance of his health. History of present illness reveals that his temperature is normal at 36.6 degrees Celsius, pulse rate is 87, respiratory rate is 18, and blood pressure is at 110 over 70 mm Hg and ECG result of an elevated ST segment.
Nikolai’s father is also suffering from coronary artery disease such as angina, but was able to cope up through diet and exercise. His mother is diagnosed with high-blood pressure due to unstable blood pressure since she was 40 years-old. His grandfather from his mother’s side died of a heart attack fifteen years ago. Some of his relatives are also suffering from several heart ailments such as myocardial infarction, heart failure, and cerebrovascular accidents.
Social history involves his poor sedentary lifestyle, such as eating foods rich in fats, oil, and sugar in all of his diet without any control. He often likes sweet foods and usually eats junk food in between meals such as recess hours during the work. Nikolai is occasionally in a drinking spree for at least twice a week. He is also known to smoke at least 10 sticks of cigarette per day, but he can smoke at many as 1 pack of cigarettes containing 20 sticks or even more whenever he is on a drinking spree. As for the Review of Systems, the eye is normal with no signs of distress. Ears are normal. Swollen lymph glands are negative. His respiration is normal, but with a mild bacterial infection. Cardiovascular system reveals that he has angina. Gastrointestinal system is not in distress. Skin is pale with no signs of infections or allergies. He is mobile with no signs of musculoskeletal distress. He has normal reproductive and excretory without feeling any distress whenever he is going to the toilet and urinate.
Variables affecting Nikolai’s health
As for his age, Nikolai is 41 years-old and he is at that age where other people are also developing similar conditions such as angina or as worse as myocardial infarction. Age is a non-modifiable factor for individuals like Nikolai because it is a stage wherein the body starts to degenerate due to the loss of several hormones, tissues, and cellular components in the body. In this case, the body of patients like Nikolai can easily develop fatty deposits along the arterial walls of his coronary arteries and other parts of his circulatory system. At the age of 40, the fibrous component, elasticity, and the collagen of tissues, organs, and other structures across the body slowly degrade, allowing other invasive particles and microorganisms to settle.
The spiritual variable associated with Nikolai is that he is of the Roman Catholic denomination, which is his main religious affiliation. His divine perception is not as strong as that of other religious practitioners because he still believes that his lifestyle is more associated with the influence of his present history of medical illness. However, divine intervention is still significant to his physiological well-being. Seeking divine intervention allows his emotional stability to relax and feel the comfort of the environment. Through prayers, he believes that it plays an important role in stimulating his pituitary gland to release hormones that will dilate his cardiovascular structures such as the blood vess...
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