The Health History of a Patient

Health history assessment conducted on George on the fifteen of February 2010 at approximately one o’clock. George is a fifty-four year white male married with three adult children and two grand children. He has been working as a teacher for over twenty years a local middle school. This paper will highlight George’s health care issues and will identify five nursing diagnosis for him. Methods of Health History Interview Methods Informed consent obtained and applied the principled of privacy and confidentiality in the interview.

Some communication skills used the interview such as touching, giving instruction, using a normal voice, leaning the body forward, introduction of self, paraphrasing, reflection and summarizing. Closed-ended questions like “ are you ready? ’ or facilitation questions which allow George to further give details on how he was diagnose after his father became gravely ill, which allowed communication to remain therapeutic. Jarvis state that the nurse brings knowledge from the physical, biological and social sciences to the assessment.

This knowledge enable the nurse to ask relevant questions and collect relevant physical assessment data related to the client’s expectation of care and underlying health care needs. Clarification questions are significant especially in George’s case where he admits to not being complaint in medication and lifestyle over the last five years. Silent would be appropriate at this time, allowing George to therapeutic communicated. Jarvis mention that respect for a person means treating patients as people with rights. It means respecting an individual‘s autonomy, protecting, and the ensuring duty of truthful.

Open-ended question offers George the opportunity to express what was difficult about being complaint with his medications. Listening and being attentive to the personal information he was sharing during the assessment . While carefully observing George‘s non verbal communication. George did not appear to be defensive to any of the question and did not receive any non-therapeutic feedback Health History George states he been healthy most of this life and then approximate five years ago, he was diagnose with coronary artery disease and non-insulin depend diabetic, hypertension, hypercholesterolemia, gout, and GERD in 2000.

George had an angioplasty with one vascular stent to the lateral anterior diagonal and one vascular stent to the circumflex in 2005, angioplasty with vascular stent to the right coronary artery in 2008, angioplasty with re-vascular stenting the lateral anterior diagonal and one vascular stent to the distal circumflex in 2009. He also transition to being a insulin dependent diabetic in 2009 and has coronary by-pass graft (CABG) surgery. His surgical history was cholecystectomy in 2007, right knee surgery in 1993, and CABG time five in 2009. He is an ex-smoker who stopped after his CABG in September 2009, 10/day for 30-40 years.

His current medication included Metoprolol 25 m BID, Simavastatin 40 mg daily, Lisinopril 5 mg daily, Coreg 12. 5 mg daily, Cymbalta 60 mg daily, Metanx tables daily, Novo Log 200units daily, Lantus 160 units daily. George has no known allergic and last examination was with his cardiologist February 4, 2010. George’s Family History His family history reveals that is father and father’s mother had coronary artery disease. His mother is a diabetic and her mother died of a cerebral vascular accident at the aged of seventy-six. His father passed away at eighty-four years of aged and his mother died at the age of eighty-five.

His sister at the aged of fifth-five has hypertension. Nursing Diagnosis Caregiver Role Strain risk for relate to unpredicted illness. Health teaching will be providing information on disease process and management strategies. Encourage caregiver to set aside time for himself. This could be as simple as a relaxing bath, a time to read a book, going out with friends. Acknowledge to caregiver the role he is carrying out and its value. Teach caregiver to identify how important it is to feel appreciated for their efforts. Encourage care recipient to thank caregiver for care given.

Provide time for caregiver to discuss problems, concerns, and feelings. Ask caregiver how he is managing, Inquire about caregiver’s health. Refer to social worker for referral for community resources and/or financial aid, if needed. Cardiac Output, decreased. Health Teaching will cover the administer medication as prescribed. Explain symptoms and interventions for decreased cardiac output related to etiological factors. Explain drug regimen, purpose, dose, and side effects. Explain progressive activity schedule and signs of overexertion. Explain diet restrictions (fluid, sodium).

Follow up with Dr Farhoud, cardiologist as direct or needed. Pain Chronic related to impaired comfort. Health teaching will be providing teaching on neuropathy and medication as directed. Teaching about using no pharmacological pain management strategies for example:Cold/heat applications, progressive, relaxation, imagery, and music. Teach the patient and family about the use of pharmacological interventions for pain management. Follow up with Dr Guthrie, endocrinologist, as directed or as needed. Interrupted family Processes related factors: illness of family member.

Health Teaching will be providing opportunities to express concerns, fears, expectations, or questions. Encourage family members to seek information and resources that increase coping skills. Assist family in breaking down problems into manageable parts. Assist with problem-solving process, with delineated responsibilities and follow-through. Identify community resources that may be helpful in dealing with particular situations (e. g. , telephone hotlines, self-help groups, educational opportunities, social service agencies, and counseling centers).

Health –Seeking Behaviors Health teaching in assisting the patient in developing a self-contract to enhance the patient control over behavior and sense of competence. Allow periodic evaluation, feedback, and revision of health plan as necessary. Reward positive efforts and achievement. Guide the patient in setting realistic goals. Prepare for lapses and relapses . Learn relaxation techniques to reduce urge (e. g. , make self-limp, visualize a soothing, pleasing situation). Breathing exercises help release tension and overcome the urge to smoke. Seek social support.

Refer patient to self-help groups as appropriate. Conclusions: The interview results to indentify five nursing diagnosis and health teaching. It indicated that people do have physical and psychological changes; with medical problems. George has declared that after the CBAG that he is fortunate to get a second chance. He has quit smoking and has been extremely obedience with his self-care behaviors. He will continue to seeking medical advice from all his physicians. He has been more accountability and conscious of his health care needs and issues.