Conduct a health history on a family member or friend. Be sure they give you permission. Using the interviewing techniques learned 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:
Title: Comprehensive Health History Analysis of a Family Member
Introduction:
A health history assessment is a crucial component of the nursing process, providing valuable insights into an individual’s health status, risk factors, and potential interventions. In this report, a comprehensive health history assessment of a family member, referred to as the interviewee, has been conducted using the interviewing techniques learned within the nursing profession. The purpose of this assessment is to gather pertinent information regarding their health conditions, lifestyle factors, medical history, and overall health status. This report will provide a summary of the health history using a structured format and address specific questions posed in the assignment prompt.
Background Information:
The interviewee, Mr. X, is a 65-year-old male who has granted permission for this health history assessment. He is my father and has a history of hypertension and type 2 diabetes. He resides in a suburban area and lives with my mother. Mr. X has a sedentary lifestyle due to his retirement from a physically demanding job. He often exhibits dietary non-compliance, consuming high-fat and high-sodium foods despite strict dietary instructions from healthcare professionals. He also smokes approximately one pack of cigarettes per day. Mr. X is under the care of a primary care physician, endocrinologist, and cardiologist, and takes medication for his hypertension and diabetes, as prescribed.
Health History Assessment:
1. Chief Complaint:
Mr. X’s chief complaints include increased blood pressure readings, frequent episodes of high and low blood glucose, and occasional dizziness.
2. Present Health Status:
Mr. X reports feeling fatigued and experiencing occasional shortness of breath. He notes recurrent headaches, especially in the morning. Additionally, he reports occasional chest discomfort and irregular heartbeat.
3. Past Medical History:
Mr. X has a history of hypertension, diagnosed 10 years ago, and type 2 diabetes, diagnosed 8 years ago. He has been prescribed antihypertensive medications (lisinopril) and oral hypoglycemic agents (metformin) to manage these conditions. He also underwent a coronary angioplasty procedure 3 years ago due to a myocardial infarction.
4. Family History:
Mr. X’s father had a history of hypertension and died from a myocardial infarction at the age of 72. His mother had type 2 diabetes and passed away from complications related to diabetes. His sister has been diagnosed with hypertension, and his brother has type 2 diabetes.
5. Lifestyle Factors:
Mr. X has a sedentary lifestyle since retiring from his job as a construction worker. He struggles with weight management and poor dietary habits, consuming high-calorie and high-sodium processed foods. He admits to regular alcohol consumption but denies any illicit drug use. Additionally, he smokes approximately one pack of cigarettes per day.
6. Review of Systems:
a) Cardiovascular System: Mr. X reports occasional chest discomfort and palpitations. No edema or intermittent claudication noted.
b) Respiratory System: Occasional shortness of breath, especially during physical exertion or climbing stairs.
c) Gastrointestinal System: Reports occasional heartburn and indigestion but denies any significant changes in appetite or bowel habits.
d) Genitourinary System: Reports occasional nocturia but denies any urinary incontinence or difficulty voiding.
e) Musculoskeletal System: Reports occasional joint stiffness, particularly in the morning, but no limitation in range of motion.
f) Integumentary System: No significant skin changes or lesions noted.
g) Neurological System: Occasional headaches, especially in the morning.
h) Endocrine System: History of type 2 diabetes, managed with oral hypoglycemic agents.
i) Hematologic System: No significant history of bleeding disorders or anemia.
7. Medication History:
Mr. X is taking lisinopril, an angiotensin-converting enzyme (ACE) inhibitor for hypertension, and metformin, a biguanide for type 2 diabetes. He reports taking these medications regularly but occasionally misses doses.
8. Allergies:
No known allergies to medications or any other substances.
9. Immunizations:
Up to date with routine immunizations.
10. Social History:
Mr. X is retired and receives pension benefits. He is married and lives with his wife. He enjoys watching television, reading books, and socializing with friends. He has a history of occasional alcohol consumption but denies any current illicit drug use. He admits to smoking approximately one pack of cigarettes per day for the past 40 years.
Summary:
In summary, the health history assessment of Mr. X revealed a 65-year-old male with a history of hypertension, type 2 diabetes, and a previous myocardial infarction. He has significant lifestyle risk factors, including a sedentary lifestyle, poor dietary habits, regular alcohol consumption, and smoking. Mr. X experiences fatigue, occasional shortness of breath, headaches, and occasional chest discomfort. He is under the care of multiple healthcare providers and is compliant with medication regimens, although occasional non-compliance is reported. Further evaluation and interventions focusing on lifestyle modifications, medication adherence, and management of comorbidities are essential to optimize Mr. X’s overall health and reduce the risk of cardiovascular complications.