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J.B is a married man living with his wife and a dog, diagnosed with Rheumatoid Arthritis, hypertension. Nurse Lauren is interview the patient for a comprehensive health history

 

1- Review of systems: Integumentary :Skin: Ask about change in skin color/texture, excessive bruising, itching, skin lesions,sores that do not heal, change in mole. Do you use a sun screen? How much sun exposure do you experience?

 

Hair: Ask about changes in hair texture and recent hair loss.Nails: Ask about changes in nail color and texture, splitting, and cracking.

HEENT Head: Ask about headaches, recent head trauma, injury or surgery, history of concussion,dizziness, and loss of consciousness.Neck: 

 

Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the neck

 

.Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain,floaters, halos around lights, flashing lights, light sensitivity, and difficulty reading. Do you use corrective lenses (glasses or contact lenses)?

 

Ears: Ask about last hearing test, changes in hearing, ear pain, drainage, vertigo,recurrent ear infections, ringing in ears, excessive wax problems, use of hearing aids.

 

Nose, Nasopharynx, Sinuses: Ask about nasal discharge, frequent nosebleeds, nasal obstruction, snoring, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain, sinus infections.Mouth/Oropharynx: Ask about sore throats, mouth sores, bleeding gums, hoarseness,change voice quality, difficulty chewing or swallowing, change in taste, dentures and bridges.

Respiratory:Ask about frequent colds, pain with breathing, cough, coughing up blood, shortness of breath, wheezing, night sweats, last chest x-ray, PPD and results, and history of smoking.Cardiovascular. Ask about chest pain, palpitations, shortness of breath, edema, coldness of extremities,color changes in hands and feet, hair loss on legs, leg pain with activity, paresthesia,sores that do not heal, and EKG and results.

 

2-Health practices and beliefs/self-care activities: Ask about type and frequency of exercise, type and frequency of self examination, oral hygiene practice (frequency of brushing/flossing), screening examinations (blood pressure, prostate, breast, glucose, etc.)

 

3-After the interview identify 1 physical strength, 1 psychosocial/cognitive strength, and 1 weakness in either category. State why you think this to be true.With the information you collected, you can begin developing an idea of a client’s weakness and strengths. What is a strength? This might be that a person’snutritional status appears to be excellent. It may be that there is no impairment o fmobility. They may have lots of friends with them so be socially active. What is a weakness? This might be that a person does have impaired mobility or perhaps imbalanced nutrition – more than or less than body requirements. It might be that they have a communication issue that you note or perhaps seem to have a depressed mood, seem alone/isolated

SCIENCE
HEALTH SCIENCE
NURSING
QBAZ NUR2180