Comprehensive Health History: Areas Of Health Promotion

To provide the student with an opportunity to practice performing a comprehensive health history on a client. This will be done on an adult of the student’s own choosing. Areas of health concern will be identified to determine health promotion needs in conjunction with the client.

You will be assessed on how you apply an understanding of the following general learning outcomes:

• conduct a health history interview of a client
• validate and document the findings of the health history
• determine health promotion and disease prevention needs requiring client teaching

Part 1 – Interview Preparation:

1. Find a client, with a stable medical health condition, who is willing to participate in your health history assignment and meets the criteria below:
2. an adult aged 16-64 (e.g., friend, family member or peer who is not your partner in this assignment) or,
3. an older adult aged 65-up (e.g., friend, family member)
4. Provide the client with the following background information prior to setting up an interview. It is important to communicate to the client the process and purpose of this interview:
5. no personal identifiers will be recorded on the form (only the client’s initials will be recorded)
6. the interview process is private and client’s recorded information is confidential
7. the interview may take approximately one hour
8. the purpose of this assignment is to help me (the student) practice collecting health history data from a client
9. if the client feels uncomfortable answering a question, indicate the reason why (if provided), otherwise record the data as ‘client declined’ for that question  

Record data in each section listed on the form. If the client indicates that there are ‘no issues’ in a section, indicate that response beside the question. If the client was uncomfortable responding to a section, indicate that response beside the question.

1. Biographical Data (only: initials, identified gender, age, birthplace, marital status, occupation, collection date/time), p. 66
2. Health History Information, pp. 67-69
3. Review of Systems, pp. 69-72
4. Cultural and Social Considerations (related to health and health care), p. 69
5. Functional Assessment, p. 72 (if you are choosing an older adult, refer to pp. 77-81 and chapter 31)
6. Perception of Health
7. Conduct the health history interview with your client
8. After collecting the health history data, ask the client the following questions and record it in the Perception of Health section of the form:
9. to describe their perception of their health
10. to identify two primary areas of health concern and ask the client why these areas of concern were identified

After the interview has been completed, indicate what two areas you feel should be addressed with health promotion materials/teaching recommendations for the client. Provide a rationale why you choose the two areas and identify one health promotion material for each area. Record this in the Areas of Health Promotion section of the form

Interview Preparation

Current Health Status(a short statement about present state of health; provide chronological record of current health problems):

Q: “Please tell me about your current health status”?

A:I am presently suffering from asthma. My asthma was diagnosed when I was 5 years old and has been taking asthmatic medication since then. I am also over-weight and I face difficulty while climbing upstairs. .

Past Health History(list childhood illnesses, accidents or injuries, chronic illnesses,mental health concerns, hospitalizations, operations, obstetrical history, immunizations, most recent examination dates for physical, dental, vision and hearing):

Q: “Please tell me about your past health history”?

A: I had epilepsy when I was young, During my teen’s I had knee surgeries and hernia operation. I also dealt with mental health issue and went for counselling for seven years due to bulling, physical and sexual abuses. During my late twenties I dealt with appendix attack and was about to die. I was also hospitalized seven times for pneumonia and twice for dental surgeries. Recently I had encountered heart attack (one year ago for stress).

Past Family History(ages/health concerns, age at and cause of death of blood relatives – parents, grandparents, siblings):

Q: “Please tell me about your past family history”?

A: Heart attacks, brain tumour, gallbladder attack rare running in my family. My maternal grandfather had a brain tumour when he was in his late forties and underwent surgery for this at the age of 50. He later died from heart attack when he was seventy- nine years old. My maternal grandmother had emphysema and died when she was 80 years old.

On my father’s side, my grandmother is deceased and had suffered from Multiple sclerosis (MS) for thirty years. She developed it when she was twenty-fourth years old. My paternal grandfather has mild heart failure and is still alive. My sister has epilepsy. She had developed it when she was only twelve years old and take medication for it. Both my parents are healthy.

Allergies:

Q:“Do you have any allergies”?

A: I am allergic to uncooked egg whites and peanuts. When I develop any allergic reactions I take epipen. I also frequently develop cold and cough which I also consider as hypersensitivity reactions and take Benadryl for it

Prescribed Medications/Over-the-Counter:

Q: “Do you take any prescribed medication or over-the -counter”?

A: I take Butamol and Flovent to prevent asthma attacks and aspirin for heart attack and stress. I mainly take prescribe dosage of medication. However, at times I indulge in over-the-counter medication in order to cope with stress and headache. The main medication I take for this is Aspirin.

Review of Systems

List your questions in each section prior to the interview

(if no concerns, check the No column; if concerns, check the Yes column and specify with details)

History of Concern No Yes if Yes, specify concerns here

Respiratory System:

Q: Do you have a cough?Is your cough dry or productive?

Q: Have you ever had any shortness of breath or a hard-breathing spell? What bring it on? How severe is it? How long does it last?

Current Health Status

Q: Do you experience chest pain, nausea, heartburn?

Q: Have you been diagnosed with asthma, emphysema or bronchitis?

Q: Have you had any surgery/trauma/test on your lungs and chest?

Q: Do you smoke? If yes,howmuch, frequency, and What age did you start/stop?

Q: Do any of your family members have respiratory problem?

As per the patient, his tendency of developing cold and cough especially cough increased after he diagnosed with asthma. The patient mainly have dry and non-productive cough which is another symptom of asthma

Patient had shortness of breath while doing physical activities and it last about a minute.

Patient experience chest pain. Chest pain mainly occurs during the onset of asthmatic attack. During asthmatic attack the heartburn becomes sound and doctors recommend to take medications of GERD (gastro-esophageal reflux disease)

Patient was diagnosed with asthma when was younger and still has it. Patient have been diagnosed with bronchitis 3 times in his life

Patient started smoking when he was 16 years old and has stopped smoking when he was 25 years old. Patient used to smoke about 2 packs of cigarette a day.

Patient’s grandmother and aunt had respiratory problems due to smoking, they had been active smoker for 25 years of their life.

Cardiovascular System:

Q: Do you experience any chest pain?

Q: Do you experience heart palpitation /irregular heart beat?

Q: Do you experience any dizziness?

Q: Do you have a history of heart problems such as heart defect/murmur?

Q: Have you had rheumatic fever

Q: When did you last have your cholesterol test?

Q: Haves any of your family been diagnosed with high blood pressure (hypertension); heart defect; high cholesterol or heart attack (myocardial infection)?

Q: When was your last BP/pulse checked?

Q: Do you drink alcohol? If yes, how much, frequency, and when did you start?

Q: Do you exercise? If yes, type, frequency, and when did you start?

Q: How many pillows do you sleep with?

Patient’s experience heart burn especially after the onset of asthma and then take medications of GERD

Just after mild to moderate exercise or while climbing upstairs, when experience heart palpitation along with shortness of breadth

Patient has encountered heart attack last year and the reason highlighted behind heart attack is stress

Patient once had rheumatic fever when he was 10 years old and was under antibiotic medication and Denadryl.

Patient has last checked his cholesterol one moth back. The test reported 140 mg/dL cholesterol which is borderline high (normal range: less than 100 mg/dL) (Hall, 2015)

Patient reported that his grandfather had hypertension and died of heart attack

Patient started drinking alcohol when he was 16 years old. He used to drink alcohol one a week and have ceased alcohol intake when he encountered stroke last year

Exercise done by the patient is walking for half an hour during the morning, before breakfast at around 8 am.

Two pillows made or natural latex as it deter dust mites and offer an optimum level of breathability

Gastrointestinal System:

Past Health History

Q: Do you currently experience abdominal pain? PQRTU

Q: Do you experience any nausea/vomiting /bloating with the pain?

Q: Do you have diarrhea or constipation (describe the color/consistency? Is this a change from normal?

Q: Have you noticed a change in your urine?

Q: Have you had any abdominal surgeries?

Q: Have you been diagnosed with acute/chronic abdominal conditions such as colitis/ Crohn’s /diverticulitis?

Q: Have you had any bladder infections?

Q: Do anyone in your family have of: abdominal cancer, kidneys disease and pancreatic disease or cancer?

Patient experience mild to moderate abdominal pain along with heart burn. It is diagnosed as the symptoms of GERD. The pain score is 5 out of 10

Frequent burping and coughing of GERD is associated with vomiting and nause

For appendicitis. The diameter of appendix is 15 cm ( Normal diameter is 7 to 8 mm; Hall, 2015

Head, Eyes, Nose and Sinuses, Mouth and Throat, Neck:

Q: Do you currently experience headache or neck pain?

Q: Have you noticed any lumps or swelling in your neck? If yes, do you have difficulty swallowing?

Q: Have you had any surgeries/injuries to the head/neck?

Q: When was your last dental visit?

Q: Have you had problems with bleeding gums or nosebleeds?

Q: Family history of head and neck problem, thyroid cancer?

Q: Family history of migraine headaches?

Q: Has your sense of taste/smell change?

Patient experiences headache and takes aspiri

7 years back for the surgical excision of wisdom teeth

Yes both the parents of the patient had history of migraine during their young adult stage. The symptoms sublimed with their age

Neurological System:

Q: Have you ever had a previous head injury?

Q: Do you experience any numbness or tingling in any extremity? What precipitates it? How long does it last?

Q: Have you ever had a seizure? Type and what precipitates the seizures?

Q: Do you experience ringing in the ear/dizziness or problem with balance?

Q: Do you experience any shakiness or tremor to the hands/arms/legs/feet?

Q: Have you noticed a change in short-term or long -term memory?

Q: Have you ever been diagnosed with meningitis, stroke, spinal cord injury or Lyme disease?

Q: Do anyone in your family have a history of hypertension, cerebral vascular accidents, Alzheimer’s?

At times patient experience tingling sensation in a mild to moderate form and this might the reason underlying the past reported case of epilepsy

When the patient was suffering from Epilepsy we use to seizures. Generalised seizures used to occur in the right and left hemisphere of the brain. These seizures are characterised by absence seizures (petit mal) tonic-clonic or convulsive seizures(grand mal) . The seizures used to precipitates only under the application of medication.

Patient was diagnosed with stroke last year. He was hospitalised for this for the past one week and was then released. Due to stroke, the patient does not encountered any paralysis

Patient’s maternal grandfather had hypertension. He later died in stroke. Both father and mother of the patient are healthy

Urinary System

Past Family History

Genital System:

Q: Sexual orientation?

Q: Do have any STI’s?

Q: How many partners had you been with?

Musculoskeletal System:

Q: Do you have any joint/muscle or bone pain or stiffness?

Q: Do you notices any muscle weakness?

Q: Have you had any problems with or received /joint/bones

Q: Does anyone in your family have diabetes/arthritis/gout/osteoporosis/lup

Patient experiences stiffness in the knees as he knee surgery during his teens

He has muscle weakness in the knees

Patient had difficulty in folding the knees at the time of running due. The patient had knee injury during his knees and for that he had underwent a operation by an orthopaedic. It is due to knee injury that the patient fail to participate in the physical activity

Peripheral Vascular System:

Q:Do you have pain, heaviness or aching in your legs?

Q: Do you have a history. Of blood clots?

Q: History of heart disease/high cholesterol level?

Q: Have you had a sore on your limbs that did not heal easily?

Q: Has anyone in your family been diagnosed with the following?

• Diabetes
• High blood pressure
• Heart disease
• Peripheral vascular or arterial disease
• Varicose vei

The patient has pain and heaviness in this knee joint

During teens, he feel down from height and due to this he experienced blood clot in his knees for which he underwent surgery for the removal of blood clot and fixation of the joint. After the he had no history of blood clot and underwent normal wound healing

He had high level of cholesterol for the past 7 years. The last month cholesterol test reported 140 mg/dL cholesterol which is borderline high (normal range: less than 100 mg/dL)

Maternal grandfather had history of hypertension and heart disease

Q: Have you notice any change in your skin, hair or nails? Any moles?

Q: Any hair loss?

Q: Have you notice any bruising?

Q: Do you experience any itching?

Q: Is there a history of skin cancer in your family?

Q: How much time do you spend in the sun or use a tanning salon?

Patient is experiencing hair loss for the past 5 years after the onset of the anti-cholesterol medications. The long-term use of cholesterol lowering medications cause rapid loss of hair

Patient once experience itching in the groin area during his college days due fungal infection and lack of proper hygiene. Later anti-fungal medication helped in rapid cure of the disease. After that no further complications was noticed related to fungal infection

Patient do not use tanning salon

Hematological System:

The complete blood hemogram or complete blood count (CBC) of the patient done last month showed normal count of the blood cells and platelletes

Do you experience any complications in sex hormones, thyroid hormones and adrenal hormone

No complications in the hormonal activity have ever been noticed. However, the patient is gay.

Nutritional (list special diets, allergies, unintentional weight loss/gain, tube feeding, etc.):

Patient does not follow any special diet plan in order to reduce his level of blood cholesterol or obesity. He is not serious about his weight loss issue.

Allergies

Cultural and Social Considerations

List your questions in each section prior to the interview

Spiritual, Religion

(list any spiritual or religious traditions/practices that the client feels needs to be part of their care?):

(list any ethnic or culturalpractices that the client feels needs to be part of their care):

Client belongs from the ethnic minority Dene and thus he prefers presence of aboriginal male nurse while discussing his sexual orientation and other health-related complications

Functional Assessment

List your questions in each section prior to the interview

Make his own meal and for his partner

Take the prescribed medications

Pay bills online

Shop for groceries online

Take all the financial decision for the family

Activity and Mobility:

What kind of physical activity you perform daily

No activity and mobility apart from 30 mints walk in the morning. He mostly lead a sedentary life both at home and while at business.

Please tell us about the exact duration of sleep and rest per day

He sleeps for 5 hours a day due to stress in his own business. He sleeps late night from 2 am to 7 am. Apart from this, he has no rest. However, his main work culture is sedentary

The patient does not follow any special diet. According to him, “since I cook my own food and need to do my own groceries and  shopping, I thrive on ready to cook or ready to eat food. Doctor had however, recommended me to low cholesterol diet but I hardly get time for that”.

Interpersonal Relationships and Resources: Please share you inter personal relationship

“ I do not share strong intrapersonal relationships or healthy community life. My sexual orientation s not straight as you know and I am a gay and thus I mainly become victim of social isolation and bullying. This is the reason why I left office and started my own business and I prefer to stay indoors and hardly communicate with other apart from my partner”.

Coping and Stress Management: what kind of coping skills you follow

“I do not have any strong or specific coping skills. Whenever I feel low or depressed, I talk with my partner. He is all I have in my life to share my grief and sorrows. At times I listen to music and I think it is a huge stress reducer. I am not very fond of movies and there are no specific movies which uplift the emotions and turmoil of the homosexual community”.

Smoking History, Alcohol and Substance Use:

“During my teens and young adulthood, I used to smoke and drink a lot. I was a chain smoker and used to smoke two cigarettes packet per day. I use of smoke and drink in order to cope up with my different sexual orientation which I started realizing when I attained puberty. However, when I encountered stroke and other complications in health, I gave up smoking and drinking altogether”

Environmental Hazards:

Patient most remains indoors and there are no specific environment hazards that he experiences in this daily living

Prescribed Medications/Over-the-Counter

Occupational Health:

His occupational health has no significant attraction and he operates his business online while staying indoors at home. His main concern is sedentary mode of work culture

Perception of Health

Describe the client’s perception of their health:

The client perception of health is, “I know that I am ill, I was never fit since my childhood. My past history will tell you about my health related condition. At present I am suffering from asthma since from my childhood and I take medications for it regularly. I also take medications in order to work on my high level of blood cholesterol. I also know that I am over-weight. However, my knee pain and my shortness of breath prevents me from indulging into physical exercise and I single headedly fail to manage my diet plan accordingly”.

Thus from the excerpts of the client that he is well aware of his health condition but is unable to do something fruitful in order to improve his health condition. I think though he is aware about his health condition, he is not awareness is overall affect on health in near future and this is the reason why he is reluctant in taking some serious initiatives for this health. Proper health education and assistance will help him to indulge in healthy lifestyle.

Indicate what the client feels are their two primary areas of health concern:

Two factor that the client feels which must be taken care of

1. Obesity: “It is due to my over-weight that I feel my partner is getting bored of me and I am also experiencing extreme fatigue”
2. Asthmatic attack: “I am tired to having asthmatic medication since childhood I need a complete remedy from this

Please thank your client at the end of the interview for volunteering their time to help you develop your data collection skills!

Dear DB than you for giving us your valuable time in discussing your health-related history in detail with us. We are grateful to you for this. Your honest answers will help us to identify your primary health concern and take steps accordingly

Areas of Health Promotion

This section to be completed without your client present

Indicate here what you think are the client’s primary health concerns and provide rationale

Primary Health Concern (1): Weight Management

I think the primary concern is weight management as reduction in the overall weight of the patient will help to overcome shortness of breath, pain in the knee joint for being over-weight and regulation of the blood cholesterol level. According to Gibson (2013), obesity increases the level of fat deposition in the lungs. The fat deposition in the lungs increases the level of complications of asthmatic patients as he feels that they experiencing difficulty in breathing. Moreover, obesity increases the risk of developing GERD (as in case of D.B) which worsen the overall prognosis of asthma. Baruwa and Sarmah (2013) are of the opinion that loosing weight helps in reducing the severity of asthma and thus helping to improve the quality of life of D.B. The reduction on the body weight in case of D.B will occur through effect management of diet plan. This diet plan will main include cholesterol free diet. Decrease in the level of blood cholesterol will reduce the tendency of cholesterol deposition in the pulmonary arteries and thereby helping to reduce the severity of asthma (Ramaraju et al., 2013). Hardcore physical activity is not an option for D.B as he already had a knee surgery and frequently suffers from knee pain. In this case, proper diet management and mild to moderate walk will be effective.

Primary Health Concern (2): Community engagement

DB reports that he does not have an active social or community life. Because he frequently experienced bullying and social exclusion. He also has previous heath history of mental health complications due to social isolation for which he had counselling. Increase in the community engagement among the gay community members and in the presence of aboriginal nurse will help him to overcome his sense of social isolation. This will help him in indulge in free communication with other members for the society like the heterosexual people (Rosenberger et al., 2014).  Increase in community engagement will help to increase his disease awareness and will make him more serious and conscious about the disease management via abiding proper diet plan. Moreover, increase community engagement will help him to overcome his sedentary mode of life style and indulge in mild to moderate physical activity like gardening, walking. This will further help to reduce weight. Moreover, community engagement will help to improve his mental health state (Seymour et al., 2013).

Reference

Baruwa, P., & Sarmah, K. R. (2013). Obesity and asthma. Lung India: official organ of Indian Chest Society, 30(1), 38.

Gibson, P. G. (2013). Obesity and asthma. Annals of the American Thoracic Society, 10(Supplement), S138-S142.

Hall, J. E. (2015). Guyton and Hall textbook of medical physiology e-Book. Elsevier Health Sciences.

Ramaraju, K., Krishnamurthy, S., Maamidi, S., Kaza, A. M., & Balasubramaniam, N. (2013). Is serum cholesterol a risk factor for asthma?. Lung India: official organ of Indian Chest Society, 30(4), 295.

Rosenberger, J. G., Schick, V., Schnarrs, P., Novak, D. S., & Reece, M. (2014). Sexual behaviors, sexual health practices, and community engagement among gay and bisexually identified men living in rural areas of the United States. Journal of Homosexuality, 61(8), 1192-1207.

Seymour, J. E., Almack, K., Kennedy, S., & Froggatt, K. (2013). Peer education for advance care planning: volunteers’ perspectives on training and community engagement activities. Health Expectations, 16(1), 43-55.