Relationship to Client: Mother II. HEALTH HISTORY Present health history Client claimed that to be in good health until she then experienced some health problems for about two months now . The health problems are minor as the most studying students have . The client has complained about her irregular sleeping habits . She said that she is only been getting three to five hours of sleep a day which makes her feel stress to work on her daily activities .
According to her, she encounters this problem when she is emotionally and physically stressed out but she never tried any medication for treatment instead, she only need some sleep . Sometimes she experienced muscle pains particularly on her lower extremities . She claims that prolonged standing or walking causing her this problem .
Past health historyDuring infancy years, the client did not experience any sickness according to her mother . During childhood years, the client suffered from chicken pox, mumps, sore eyes and ear infection caused by impacted cerumen . Client had complete immunizations . During teenage years, the client experienced irregularity of menstrual period . But it was only on her first year of menstruation and now her menstruation is regular .
The client has no known drug, food, or environmental allergies. The client has not undergone any major surgeries and serous illness . Client has been seen by her family doctor December 28, 2012 due to fever and had dental check-up October 15, 2012 . She never had seen an optometrist . Family history
The client’s grandfather is suffering from second heart attack butunder medication and most of her family members like her grandmother, father and uncle are suffering from diabetes mellitus . In her mother’s side, hypertension and migraine are common . The client’s grandfather on mother’s side passed away due to hypertension . Developmental Stage
Client is in “young adult” stage of development. She makes her own decision in life. She has an active social life . She goes out every weekend with her friends to watch movie, dinning and shopping . Client mentioned she is in relationship for about 3 years and feels she is emotionally stable .
According to D’Amico (2007), “Erik Erikson’s psychosocial developmental theory, the central task of young adults in their early 20s is intimacy versus isolation . During this stage, the young adult forms one or more intimate relationships . A secure self-identity must be established before mutually satisfying and mature relationship can be formed with another person” (p. 61) .
Cultural and SocialClient’s family background is from Punjab, India . Her family immigrates to Canada 15 years ago even living in Canada for that long time they still participate on all cultural programs and very traditional . She believe in Sikhism and goes to guruduwara every Sunday with her family . She graduated high school and now in 2nd year College taking business management . She has lots of friend and very close to her family . Nutrition
24-hour recall indicates diet is high in carbohydrates . Eats three meals a day and has snack . She prefers eating fast food or ready to heat food . Drinks 3 glasses of water, 2 glasses of juice and 1 coffee per day (see appendix) . According to Jarvis (2009), “Canada’s food guide recommended number of food serving per day for adult ages 19-50 females, vegetables and fruits 7-8 servings, grain products 6-7 servings, milk and alternatives 2 servings, and meat and alternatives 2 servings” (p. 201) . Exercise
Client stated she does not exercise regularly only once in two weeks she goes to the gym because of her busy schedule but she consider walking to school as her every day exercise . Client needs to adjust her schedule to exercise regularly 15-20 minutes a day. Simple exercises like stretching, meditation or yoga . Exercise and other forms of physical activity have been associated with both physical and psychosocial benefits for adults . Physical activity is body movement created by skeletal muscles that expends energy and produce health benefits (Dillon, 2007, p. 942) .
Rest and SleepClient only gets 3-4 hours of sleep every night and does not have time for nap because after school she works four hours and then do household chores and study . She always goes to bed around midnight and wakes up early at 4 am. She stated having difficulty to fall asleep, soft music sometimes helps her to fall asleep . Client main complain is not getting enough rest that’s why she feel more tired and restless sometimes .
As per clients age she needs maximum of 8 hours of sleep to be alert and less tired . Young adults need 6 to 8 hours of sleep per day . Sleeps restores, rejuvenates, and sometimes, heals the body . Lack of sleep causes fatigue, stress, depression, and a decrease in lymphatic system functioning, which increases the risk of infection and disease (Dillon, 2007, p. 158) . Stress Management
Client stated that her stress level is moderate . Like most college students she worry about assignments, exams and failing from the courses . To manage her stress she listens to music, sometimes talking or going out with her friends or yoga, which help her a lot to relax . In time of crises her family and friends always support her .
Client must do advance or group study to lessen the stress from exam . Stress and coping are the individual’s physical and emotional response to psychosocial or physical threats called stressors . Stress, in itself, is not bad . In fact, stress can sometimes motivate or enhance performance (D’Amico, 2007, p. 85) . Environment
Lives in south side of Edmonton in a three-bedroom single home with her parents . House is free from exposure to hazardous chemicals and materials . Has smoke and carbon dioxide detectors in home, has a burglar alarm system . Considers neighborhood safe and free from crimes and violence
. Police and fire departments within 5 miles from the house . Wear seatbelt while driving a car . The patient’s home and type of community can have an impact on her or his health (Dillon, 2007, p. 49) . Lifestyle and health Practice
Client does not smoke or drink alcohol . She never used recreational drugs . She occasionally goes to club with her friends . She likes to watch television and surfing Internet on her free time . During summer she prefer swimming and bicycling . She does not take any vitamins . She takes over the counter medication for headaches or colds . She drinks herbal tea for relaxation and visit her family doctor regularly for health checkups .
Has financial support from her family and own savings . According to D’Amico (2007), “Health practices are influenced by one’s health beliefs as well as economics, knowledge, and culture . Seeking health care for illness and disease is one health practice (p. 77) . Client needs health promotion instruction regarding her sleep and rest, time and exercise regularly to be more active and can concentrate on her daily living activities . Needs adequate knowledge of daily food intake servings requirement as per her age .
D’Amico, D., & Barbarito, C. (2007). Health and physical assessment in nursing (pp. 61, 77, 85). Upper Saddle River, New Jersey.
Dillon, P. M. (2007). Nursing health assessment: A critical thinking, case studies approach (2nd ed., pp. 49, 158, 942). Philadelphia, PA.
Jarvis, C., Browne, A., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2009). Physical examination and health assessment (1st Canadian ed., pp. 79, 80, 201). Toronto, ON: Elsevier Canada.
Appendix24- Hour Recall of Dietary Intake
List the individual’s food intake over 24-hour period. Include the specific amounts for each food portion (eg., ½ cup white rice with 1 tbsp. [15ml]butter; I can of pop [355ml]).
Breakfast: 1 6 0z cup of coffee with milk and 2 tsp . of sugar 180ml], 1 egg and 2 slice of white bread. 1 glass of water [240ml] .
Snack: Chocolate chips 1 bag and coke pop [355ml] .
Lunch: 1 hamburger with 1 tbsp. [15ml] of mayonnaise, large fries [160ml], coke can [355ml], ice cream 2 scoops .
Snack: Large Bag of Lays with 1 glass of water [240ml] .
Supper/Dinner: 2 breast part of Fried Chicken and 1 cup of white rice, 1 glass of orange juice [240ml] .
Snack: 1 chocolate bar .