NR 302 RUA Health Assessment

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 residing alone in a rural area with strong family support. SA perceives health as a balanced state, involving regular exercise and a nutritious diet. She describes herself as between healthy and unhealthy due to some ongoing health issues. SA engages in physical activities about once a week and maintains a predominantly healthy diet, yet she is motivated to improve her overall well-being by enhancing her exercise routine.

SA’s medical history encompasses several chronic conditions, including degenerative disc disease, hypertension, hyperkinemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis. Her surgical history includes neck and back surgeries, gallbladder and cataract removal, and a hysterectomy. Her current medication regimen consists of Spiriva inhaler, Allegra, Valium, Zoloft, gabapentin, Lopressor, and Protonix. SA’s family history reveals that both parents had hypertension, potentially contributing to her own condition. Her mother had asthma, which could have influenced SA’s respiratory health, while her father, a cigarette smoker, was diagnosed with lung cancer, and her mother also suffered from anemia, requiring multiple blood transfusions.

Review of Systems

SA has minimal skin issues, limited to eczema, with normal nails and some greying hair. She reports no headaches, head injuries, or dizziness but does experience neck pain when turning her head to the right. No lymphatic issues are present. SA’s vision is slightly compromised due to cataracts, for which she wears glasses, and she underwent cataract surgery in June 2015. Her auditory health is good, with no ear infections or hearing issues. Although she has allergies to pollen and dust, SA experiences no significant sinus problems. Her mouth and throat health is generally good, without sore throat, lesions, or toothaches. While asthma and emphysema cause occasional shortness of breath, they do not hinder her ability to perform daily activities like cooking, cleaning, and self-care. Her only cardiovascular concern is high blood pressure, which she manages through medication and reduced salt intake.

Developmental Considerations

Having dealt with asthma since childhood, SA’s health condition has shaped her lifestyle significantly. Her respiratory limitations restricted her participation in sports and prolonged physical activities, impacting her social interactions and contributing to challenges with weight management. Throughout her life, SA has associated her struggles with weight control with her asthma, as the condition limited her physical activity options.

Health Area	Assessment Findings	Developmental Impact
Health Perception	SA views health as a balance of exercise and nutrition, aiming to improve her fitness routine.	NA
Medical History	Includes degenerative disc disease, hypertension, COPD, asthma, emphysema, diverticulitis, osteoporosis, and multiple surgeries.	Health issues influence exercise limitations and overall well-being.
Family Medical History	Parents had hypertension; mother had asthma; father had lung cancer, and mother had anemia.	Increased predisposition to conditions like asthma and hypertension due to familial influence.
Review of Systems	No severe skin, head, ear, or mouth concerns. Shortness of breath from asthma and emphysema, and hypertension managed with medication.	Childhood asthma affected her ability to engage in physical and social activities, impacting her weight and social development.

Cultural and Psychosocial Considerations

SA’s upbringing was marked by an interest in religion, specifically church attendance and Bible study, though her family did not share the same religious devotion. Her father’s discouraging remarks regarding her spiritual interests created a challenging environment, which hindered her connection with her faith community. Psychosocially, the loss of her husband nearly a year ago has heavily impacted SA’s social life. She finds it emotionally difficult to attend social events, as they remind her of activities once shared with her spouse. Despite this, her children visit regularly, with one visiting daily, and they maintain a weekly family night, which brings SA comfort and a sense of companionship.

Collaborative Resources and Reflection

SA has access to strong family support, including daily visits and assistance with doctor appointments. Additionally, her religious friends offer community support through shared church attendance and weekly social gatherings, providing emotional comfort. Her neighbor also joins her for regular exercise walks, fostering a supportive social and physical environment.

Reflecting on this assessment experience, I found my health assessment skills helpful in discussing SA’s medical history. However, I encountered challenges when addressing the review of systems due to SA’s difficulty understanding specific questions. To navigate this, I explained each topic in simpler terms. In retrospect, it would have been beneficial to further explore any cultural factors influencing SA’s health experience, as this could deepen the understanding of her health behaviors and concerns.

References

American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.

NR 302 RUA Health Assessment

Jarvis, C., Tarlier, D., Pelt, L. V., Andrews, M. E., & Jarvis, C. (n.d.). Physical examination and health assessment (7th ed.).