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 who resides alone in a rural area, but has strong family support. SA perceives health as a balanced state, one that involves regular exercise and a nutritious diet. She describes herself as neither fully healthy nor unhealthy, as she has some ongoing health issues. SA engages in physical activities about once a week and maintains a predominantly healthy diet; however, she is motivated to improve her overall well-being by enhancing her exercise routine.

SA has a history of 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 includes Spiriva inhaler, Allegra, Valium, Zoloft, gabapentin, Lopressor, and Protonix. Regarding her family history, both of SA’s parents had hypertension, which may contribute to her condition. Her mother had asthma, potentially affecting SA’s respiratory health, while her father, a cigarette smoker, was diagnosed with lung cancer. Additionally, her mother experienced anemia and required multiple blood transfusions.

Review of Systems

SA reports minimal skin issues, with eczema being the primary concern. Her nails are normal, and she experiences some greying hair. She reports no headaches, head injuries, or dizziness, although she experiences neck pain when turning her head to the right. No lymphatic issues are reported. SA’s vision is slightly compromised due to cataracts, for which she wears glasses; she had cataract surgery in June 2015. Her auditory health is normal, with no ear infections or hearing issues. Although she has allergies to pollen and dust, she does not experience significant sinus problems. SA’s oral and throat health is generally good, with no sore throat, lesions, or toothaches. Despite occasional shortness of breath due to asthma and emphysema, these conditions do not interfere with her ability to perform daily activities, such as cooking, cleaning, and self-care. Her primary cardiovascular concern is high blood pressure, which she manages with medication and reduced salt intake.

Developmental Considerations

Having had asthma since childhood, SA’s health condition has significantly impacted her lifestyle. Her respiratory limitations have restricted her ability to participate in sports and prolonged physical activities, which in turn affected her social interactions and presented challenges with weight management. Over the years, SA has attributed her struggles with weight control to 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 characterized by an interest in religion, particularly church attendance and Bible study, although her family did not share the same level of devotion. Her father’s discouraging remarks about her spiritual interests created a challenging environment, which affected her connection to her faith community. Psychosocially, SA has been heavily impacted by the loss of her husband nearly a year ago. She finds it emotionally difficult to attend social events, as these remind her of activities once shared with her spouse. Despite this, her children visit regularly, with one child 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, creating a supportive social and physical environment.

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

References

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