Assessing Patient Health and Lifestyle

Health Promotion and Preventative Care Plan

The purpose of this paper is provide information about the process of conducting a health assessment and a care plan based on the findings of the several assessments that were conducted for the benefit of the patient. The paper will describe the health history consisting of a review of systems, and will provide information about the assessment and its relevance to the plan of care developed for the patient.

The patient (CM) is a 24-year-old single black female who was born in the Democratic Republic of Congo (DRC) and arrived in the United States three years ago to pursue an education. CM lives at home with her siblings, nieces and nephews, and her parents who just moved to the U.S. five months ago from the DRC. CM works in retail and has been working extra shifts in order to help with the expenses of her extended family. CM made this medical appointment for her annual check-up and also because she reports feeling quite tired lately. CM escaped typical childhood diseases except chicken pox, and she is current on her tetanus shots and MMR immunizations, and a TB test administered last September was negative. Much of CM's health history is unremarkable: she has never had a significant accident, never been pregnant or had an abortion, never been hospitalized, and never had surgery. CM has no known allergies and currently takes OTC ibuprofen (800mg) for an occasional severe headache that she rates as a 7 out of 10 on a pain scale. CM is due in June for her annual pelvic examination and an dental check-up.

Review of Systems

The review of systems (ROS) finders were as follows: Constitutional symptoms -- the patient presented with complaints of fatigue. Eyes show bilateral PERRLA. Ears, nose, mouth, & throat (ENT) were normal. Cardiovascular sounds were normal. Respiratory system normal. Gastrointestinal - Normal with patient reporting regularity. Genitourinary - Normal with patient reporting no difficulties. Musculoskeletal system appears symmetrical and normal. Integumentary/Breast exam reveals symmetry and no lumps or discharge. Neurologic -- Patient responses suggest normal short- and long-term memory, and Romberg's sign is negative. Psychiatric -- Normal. Endocrine -- Unremarkable. Hematologic/lymphatic -- Normal test results. Allergic/immunologic -- Patient reports no allergies. Vital signs were within normal limits, as follows: Temperature (98.9 degrees F.); radial pulse (84 bpm); respiration (17 breaths / min.); sitting blood pressure (110/68); standing blood pressure (112/68); oxygen saturation at room air (100%).

Genogram

The genogram revealed pertinent health information about the following people: 1) Father (DM), 67 years old, diagnosed with diabetes type 2 seven years ago; 2) mother (CM), 60 years old with occasional migraines; 3) older sister (TM), 35 years old, divorced head-of-household, mother of two biological children, ages 9 years and 7 years, with no current illness.

Culture and Spirituality

Her Christian upbringing was very influential in CM's life and she has continued with the rituals and practices she learned as a child. Her faith is strong and she does believe in miracles. CM's religion provides her with a firm foundation and a refuge from the current stresses in her life. She reads the Bible and prays with her family, all of who put God at the center of their lives.

In her homeland, extended families are the norm, so CM is perhaps more tolerant of her living situation than she might otherwise be. Regardless, the density of people in her home make it difficult for the patient to get adequate rest and find privacy when she needs it. The patient is engaged to be married and is deliberately celibate until she marries. Presently, all the adult members of the family pitch in to take care of the home, provide income, watch over the children, and support each other: the family bonds are very strong. CM's mother waits up for her during the days when she works, and this can mean a very late supper for which she often has very little appetite due to fatigue from the long hours.

Functional Assessment

CM is looking forward to getting her green card soon as it will enable her to apply for jobs that pay more and are less physically demanding than the jobs she works at now. She is a high school graduate and received on-the-job training in retail sales. Her employment does not provide sufficient wages to permit saving money for the future. Indeed, it is difficult for CM to spare enough money to help with the household expenses. Because of her very long work days, CM typically just takes fruit and a bottle of water with her on the bus -- this serves as breakfast and lets her get to work on time during the busy commute. CM dreams of becoming a physician because she enjoys helping people and comes from a culture in which caretaking is typical and appreciated, and one in which doctors are highly respected. She believes that by becoming a physician, she could help people in her homeland and in other third world countries.

Plan of Care

The basis for the care plan was the knowledge deficit related to health promotion. In NANDA, this is referred to "absences or deficiency of cognitive information related to specific topic" (Gulanick, M. (2012). The patient's overall health was considered good, which enabled the plan of care to focus on health promotion. The three primary issues for the patient are as follows: 1) A lifestyle that is stressful and does not promote healthful routines; 2) any relationship between her severe headaches (which were diagnoses as migraines) and her lifestyle -- which signals the need to determine if a prescription medication would ease her symptoms and enable her to maintain her work and family routines; and 3) to ensure the patient understands the relationship between type 2 diabetes and diet, exercise, body weight, and genetics.