Health assessment discussion 2
| Case 1 | |
| Chief Complaint (CC) | “I came for my annual physical exam, but do not want to be a burden to my daughter.” |
| History of Present Illness (HPI) | At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs. |
| PMH | Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis |
| PSH | S/P cholecystectomy |
| Drug Hx | Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily. |
| Allergies | |
| Family Hx | |
| General | + weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills. |
| Head, Eyes, Ears, Nose & Throat (HEENT) | No changes in vision or hearing, no difficulty chewing or swallowing. |
| Neck | No pain or injury |
| Respiratory | |
| CV | |
| GI | |
| GU | no urinary hesitancy or change in urine stream |
| Integument | multiple bruises on his upper arms and back. |
| MS/Neuro | + falls x 2 within the last 6 months; no syncopal episodes or dizziness |
| PE | B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8 |
| General | |
| HEENT | Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. |
| Lungs | CTA AP&L |
| Card | S1S2 without rub or gallop |
| Abd | benign, normoactive bowel sounds x 4 |
| GU | |
| Ext | no cyanosis, clubbing or edema |
| Integument | multiple bruises in different stages of healing – on his upper arms and back. |
| MS | |
| Neuro | No obvious deformities, CN grossly intact II-XII |
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
Answer the following questions about your specific case number assigned:
1. Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
2. Utilizing the five assessment domains, which ones would you utilize on your patient in conducting a comprehensive nutritional assessment?
3. Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?
Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 3 academic sources.