Report On Health History Of P.S. Patient

Introduction

P. S. is a 67-year-old Caucasian female that resides in the Chicagoland area. She lives with her husband and son in their own residents. P. S. was an entrepreneur owning multiple businesses in her lifetime. P. S. owned both an ice cream parlor and a pizza restaurant while co owning these establishments with her husband. She owned both businesses for many years running them until either deciding to sell or was bought out by other companies. The patient has also had different occupations before owning these businesses. She started out at the meat factory in the packaging department. After a few years P. S. transferred as an office assistant in the same company. She knew she wanted to be her own boss so she decided to do just that. While her medical history is on the lengthy end this does not slow her down. While enjoying retirement P. S. has taken up different hobbies such as baking/cooking, bible study and needle point. P. S. main health concerns include type two Diabetes and knee replacements.

Review of Systems

Circulatory/Respiratory

P. S. has a history of having high cholesterol. This indicates that P. S. has a high level of lipids or fats present in here blood. Also, she has a history of high blood pressure. P. S. knows that this can lead to future heart diseases so she takes preventable measures. P. S consults with her physicians on a regular basis to make sure her medications are at an effective dosage. P. S. is on multiple medications for both her high cholesterol and also high blood pressure. The patient is on one aspirin a day to help with coagulation and to thin the blood so that the blood can circulate properly in the upper and lower extremities. She knows that with being diabetic having good circulation is important. P. S. Is prescribed to take Amlodipine in which helps to regulate high blood pressure and helps with any angina the patient might experience. P. S. is prescribed to take one 5mg tablet in the morning. P. S. is also taking Losartan at 100mg tablet a day. Losartan helps with high blood pressure. It helps reduce the chance of stroke that patients with high blood pressure are at risk of if not regulated. It also can help with any enlargement of the cardiac muscle due to the continuous high blood flow. Also, Losartan can help diabetic patients who suffer with kidney disease as well. Patient is also on Fenofibrate at one 160mg tablet a day. This is to help lower cholesterol levels and also triglycerides. P. S has no known problems or disorders of the respiratory system. She has no history of respiratory infections. She stated that she has never need any types of medication for her lungs. Also, the trachea has no history of disorders or illness.

Muscular/Skeletal

Patient P. S has a history of knee problems. Patient has had a full knee replacement within the last 10-years and is currently scheduling another full knee replacement in the opposite knee. P. S is on Tramadol at one 50mg tablet a day for pain. Her knees are the main problems when assessing her. Other problems that she is experiencing are her feet. P. S. believes her feet pain is due to her knee problems. When talking to the physician they are currently monitoring this and are hoping the pain in the foot will subside after the noted knee replacement. The patient has had a hair line fracture in their left foot. The patient muscles seem to match based on the patients noted age. It is normal for older adults to see muscle loss.

Endocrine

P. S. has a long history of diabetes mellitus with type two being the specific type. Type two diabetes is when your body is making enough insulin to support the proper blood glucose. The problem is the body does not use the insulin properly in result the pancreas makes too much insulin. With having too much sugar in the blood steam the patient can have hyperglycemia. P. S. checks her blood glucose levels on a daily basis and keeps a record for the physician to make sure her levels are in a safe range and also to see if they need to change dosages on her medicine. P. S I currently prescribed with Metformin 500mg at 4 tablets before bed. Metformin is taken to help to try to regulate and treat high blood sugar levels. Integumentary P. S seems to experience a form of excoriation. This is when the patient scratches until they cause an abrasion to the skin. Patient’s skin color matched her ethnicity. No signs of discolorations. Also, patient has no visible signs of dehydration or jaundice while looking at her. P. S. has hyperactive sweat glands and is complaining of finding herself having to change outfits on average three times a day.

Lymphatic

P. S. has history of getting her tonsils removed at the age of two. She recalls also getting her adenoids removed as well. When the patient was a young child she experienced seizures due to her tonsils. Tonsillitis can cause seizures to occur. Many try to diagnose as epilepsy but it can actually be tonsillitis. Ocular Ever since P. S. was eight years old she has needed the use of glasses. The patient has myopia, in which it means the she can see near but not far objects. P. S has a family history of macular degeneration. To prevent this P. S continues her yearly check-up. The disease is the deterioration of the macula, which is in charge of vision. P. S.

Developmental Consideration

When referring to Erickson’s stages of development my patient P. S would be classified in the stage integrity vs. despair. She is in the age classification which is to be in their mid-sixties. The Lumen web source describes this stage by stating “people in late adulthood reflect on their lives and feel either a sense of satisfaction or a sense of failure. People who feel proud of their accomplishments feel a sense of integrity, and they can look back on their lives with few regrets. However, people who are not successful at this stage may feel as if their life has been wasted. They focus on what “would have,” “should have,” and “could have” been. They face the end of their lives with feelings of bitterness, depression, and despair”. After relating this theory to my patient P. S she agreed that she was at this stage of her life. She believes she falls under more integrity than despair. She believes that everyone has things in their life in which they wish they could change but she knows that she cannot. Her philosophy is to live to the fullest so to her she has no regrets. She raised a beautiful family; she accomplished her career goals, and always helped those who needed it. P. S felt that throughout her life if she felt that she did not like something that it was up to her to change it.

Cultural Consideration

When asking P. S what is kind of cultural practices do they engage in when trying to get well she explained that she does not get caught up in it. She is thinking about starting to drink herbal teas to see if they have any effects. P. S. explained she really does not get sick. She has not had a cold for many years. She is traditional when it comes to healing. If for some reason she is feeling under the weather she makes an appointment with her family physician. P. S has a regular checkup especially with her current medical issues.

Psychosocial Considerations

P. S has been married for the last 42 years to her husband W. S. They have had two children and now have a grandchild. A few years ago she lost her daughter to a sudden pulmonary embolism. While assessing P. S she seems to be battling with depression due to the tragic loss. She finds here self-becoming overwhelmed when thinking about it and began to cry. The book gives advice if this should happen by stating, “crying is a big relief to a person. Health problems come with powerful emotions, and it takes a good deal of energy to keep worries about illness, death, or loss bottled up. When you say something that “makes the person cry,” do not think you have hurt the person. You have just broached a topic that is important. Do not go on to a new topic. It is important that you allow the person to cry and express his or her feelings fully before you move on”. She also feels overwhelmed when in a large group of people. When giving an example she said she usually likes to be the first one to show up for a party. The reason is because she likes to say high to the host and move to the corner. It gives her anxiety if she shows up in the middle of the party because the other guests are all there and they will watch her enter. She likes to be in and out. P. S has a strong and wide range of support systems. She has her family, friends and she also attends support groups such as church groups. When at home P. S has the help to do everyday activities from her family. She likes to stay active but when tasks become too much her support system steps in. They also are very open with emotional support as well.

Needs Assessment

As a nurse we are the ones who assess patients to help care for them both in the hospital or facility and at home. My patient P. S can use further assistance while at home. P. S can use further education on how to use her mobile devices. While assessing her I witnessed her using her quad cane wrong and further educated her on how height of the cane is important and also which side to use it on. P. S can use further education on how to accommodate her cooking for her diabetic needs. She still likes to use some of the unhealthy choices while cooking. With further education P. S can better stabilize her diabetes. Also, P. S can use professional counseling when it comes to trying to come to terms with her daughters’ death. She is still in the grieving phase and seems to be at an unhealthy level. P. S would benefit from getting to talk about the event with someone who can help her reach peace. If the patient is not willing to go to therapy or counseling then maybe a support group with other individuals going through the same thing could help her. As a soon to be nurse I believe my patient would benefit from getting further assistants because she seems a little mentally unstable. When identifying it as mentally unstable it means in the event of the loss not in everyday living. She starts talking about the event and then thinks about what she could have done differently. I believe she feels at fault about what has happened. This is why counseling or therapy could be beneficial.

Collaborative Resources

P. S was using physical therapy as a collaborative resource. She was going once a week to a near home facility. She believed this was doing a lot of good for her. As her nurse it might be good for P. S health to continue to receive physical therapy. When assessing the situation that P. S is currently in she could use other resources help for everyday life. With her knee being so damaged and it needing to be fully replaced P. S could use meals on wheels to help her keep fresh and nutritional food coming in. When people cannot continuously go to the store they usually buy the foods that will not got bad quickly. The problems with these foods are that they are full of preservatives and that is usually meaning they are filled with sodium. As a diabetic P. S may see he sugar levels increase due to the food she has access to.

Reflection

When arriving to interview P. S at her residence the vibe entering was warm and very welcoming. She had really made me feel right at home. She offered coffee and also made a snack to share. She brought me into the kitchen and we sat at the table. My impression of the house was that you could tell she struggles to keep it cleaned. When entering the bathrooms I could not see any devices to help her into the showers or on and off of the toilet. Before beginning the interview I explained to my patient that everything was confidential and HIPPA applied into the project. She was really open with her answers and went into detail about each question I asked. It made it very easy to get her medical history for this paper. When interviewing P. S she opened up about her medical history. We went over each body system both ones e touched about in class and some we did not.

P. S has a history of type 2 Diabetes, high blood pressure, and high cholesterol. She also experiences hyperactive sweat glands and causes self-abrasions when scratching at her skin. P. S surgical history includes tonsillectomy, adenoidectomy, and soon to be two full knee replacements. P. S. stated what type of medicines she is ordered to take. P. S end of assessment results included me as her nurse recommending a dietician to better educate her on different ways to maintain her good blood glucose with good nutrition. Also, she could use some further education of using her at home devices to get around. P. S Should continue with physical therapy before and post-surgery. Finally my biggest recommendation was to seek out therapy for depression with the loss of her daughter. When self-reflecting on the interview I believe that the interview was a complete success. The interaction was easy. It was like having coffee with a friend. We both felt comfortable with each other and there was no judgment. This made the conversation flow smoothly. P. S just talked and answered each question in full detail.

The interaction made it easy to learn about the patient. P. S came into the interview ready to tell her medical story. She seemed to enjoy having a good conversation with someone. The most important thing that went well was we both were very comfortable with each other. There was little to no awkwardness between us during the interview. During the interview the barriers came up at times. P. S husband was listening in and made it harder to concentrate. Also, there was a time when asking questions he wanted to know why I needed to know so much. She looked at him and asked him to leave the room. Upon leaving it become normal again. I know there will be moments like this in the future and not everyone will go this smoothly. I have to reassure the patient that all the questions will help diagnose and treat them.

While interviewing P. S it was a surprise that her husband was getting a little offensive with the questions. When I asked her to let me do this project I explained that it will get very personal. He was talking to us when I asked and she accepted. When conducting an assessment in the future I will try gather more questions in the future than I did now. The reason for this is if the person is as open as P. S was then it is very easy to learn as much as you can from them. If they are short and to the point then learning is going to be more of a challenge. Next time I believe I will be prepared for both types of interviews. People are all different and it is hard to identify it sometimes. The interview was a success and it was interesting to see how someone’s health history is so much more complex than yours.