3 Page(s),825 Words, Double Space, 2 Sources , APA format, Nursing due in the next 12 hours Conduct a health history on a family member or friend. Be sure they give you permission. Using the interviewing techniques learned in Module 2, gather the following information. Use your textbook as your guide. While this is only a partial health history, summarize in 3 -5 pages the information you gathered. Also, answer the following questions:
Conducting a health history is an essential component of nursing practice as it provides crucial information about an individual’s health and assists in identifying any potential health issues. In this assignment, I conducted a health history on a family member, Mr. Smith, with his consent. The purpose of this health history was to gather comprehensive data about Mr. Smith’s medical history, current health status, and potential risk factors.
Interviewing Techniques:
To collect accurate and relevant information, I utilized various interviewing techniques learned in Module 2. These techniques include active listening, open-ended questions, closed-ended questions, clarifying questions, and summarizing. Active listening allowed me to focus on Mr. Smith’s responses, maintain eye contact, and provide verbal and non-verbal cues to demonstrate my attentiveness.
Detailed Health History:
During the health history interview, I gathered the following information from Mr. Smith:
1. Demographic Information:
I obtained Mr. Smith’s full name, age, date of birth, address, phone number, marital status, and occupation. This demographic information is essential for proper identification and documentation.
2. Chief Complaint:
Mr. Smith reported experiencing occasional chest pain, especially after physical exertion or a heavy meal. He described the pain as a squeezing sensation in the center of his chest that lasts for a few minutes and sometimes radiates to his left arm and jaw. This information suggests a potential cardiovascular issue that needs further exploration.
3. Present Illness:
Mr. Smith mentioned that he has been diagnosed with hypertension and has been taking medication for the past five years. He stated that his blood pressure is generally well-controlled, but he occasionally experiences headache and dizziness. He also reported occasional shortness of breath and fatigue, especially when climbing stairs or performing strenuous activities. These symptoms indicate potential complications related to his hypertension.
4. Past Medical History:
Mr. Smith disclosed a history of myocardial infarction (heart attack) three years ago, which required hospitalization and cardiac catheterization. He underwent coronary artery bypass grafting (CABG) surgery and has been on medication for the management of his cardiovascular condition since then. He further mentioned a previous diagnosis of type 2 diabetes mellitus, for which he takes oral hypoglycemic agents. Additionally, he reported having seasonal allergies and occasional episodes of low back pain.
5. Family History:
I inquired about any significant medical conditions among Mr. Smith’s immediate family members. He reported that his father had a history of hypertension, his mother had breast cancer, and his brother has type 1 diabetes. This information highlights potential genetic predispositions and risk factors for Mr. Smith’s health.
6. Social History:
During the interview, I explored Mr. Smith’s lifestyle factors and habits that may impact his health outcomes. He is a non-smoker and does not consume alcoholic beverages. He enjoys a balanced diet consisting of fruits, vegetables, lean proteins, and whole grains. He exercises regularly by engaging in brisk walking for 30 minutes a day. Mr. Smith stated that he tries to manage his stress levels by practicing relaxation techniques and spending time with his family.
7. Review of Systems:
I conducted a comprehensive review of Mr. Smith’s body systems to identify any additional symptoms or abnormalities. He denied any significant changes or new concerns in his vision, hearing, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, or nervous systems. However, he mentioned occasional nocturia (waking up at night to urinate).
8. Medications and Allergies:
Mr. Smith provided a detailed list of his current medications, including the names, dosages, and frequencies. He is compliant with his prescribed medications and has no reported allergies to any medications.
Analysis of Gathered Information:
Based on the health history interview, several potential health issues and risk factors were identified. Mr. Smith’s chief complaint of chest pain, especially radiating to the left arm and jaw, is concerning for possible cardiac ischemia. This, along with his history of myocardial infarction and hypertension, suggests a heightened risk for cardiovascular complications. His occasional headaches, dizziness, shortness of breath, and fatigue may indicate further cardiac involvement and require further investigation.
Furthermore, Mr. Smith’s diagnosis of type 2 diabetes mellitus raises the risk of microvascular and macrovascular complications such as retinopathy, nephropathy, neuropathy, and cardiovascular disease. Regular monitoring of his blood glucose levels is essential to ensure optimal management of his diabetes.
In conclusion, conducting a health history is a critical nursing skill that provides valuable information about an individual’s health status. In this assignment, I conducted a health history interview with Mr. Smith, gathering comprehensive information about his medical history, present illness, past medical history, family history, social history, review of systems, medications, and allergies. Based on the gathered information, potential health issues and risk factors, including cardiovascular complications and diabetic complications, were identified. This health history interview serves as a foundation for further assessment, diagnosis, and development of a comprehensive care plan to promote Mr. Smith’s health and well-being.