Health Assessment & Health Promotion Plan
Nurses play an important role in health promotion. Part of the health promotion process includes performing a thorough assessment of your patient’s health. This requires more than just a physical examination of your patient. It includes asking your patient several questions about his or her health history, medications, lifestyle, diet, exercise, and behaviors/habits. But the questions you ask your patient must be open-ended, so you can collect information rather than your patient just giving you a yes or no answer. This essay begins with a description of the individual I interviewed, including her age, gender, race, social circumstances, employment status, general education level, allergies, medications, any relevant family medical history, and her health literacy score. Next, I will discuss three assigned Functional Health Patterns and one additional Functional Health Pattern applicable to the individual and the questions and answers associated with them. I will identify one body system that I believe is important to assess in my client based on my discussion with her. I will then discuss why I chose to assess that specific system. A summary of what I learned about my client’s health will be included. Next, I will reveal at least three health-teaching resources that I found appropriate for my client and the rationales for why I chose them. Finally, I will reflect on my experience of being a “health coach” and communication partner in health promotion strategies.
Part One, Section One: The interviewee
The following assessment is based on a 21-year old Caucasian female who lives independently with her two-year-old daughter, whom she has 50/50 custody of. They sometimes stay with her boyfriend and his two-year-old daughter in an apartment in Farmington, Missouri. Other times she stays at her parents’ house. She is employed full-time as a server at Applebee’s restaurant and she holds an Associate Degree in Arts and Sciences with a major in History. She plans to return to college but is unsure of what course of education she would like to pursue. My client reported that she has allergies to eggs, nuts, pet dander, pollen, trees, and grass. She denies having allergies to any medications. She has a family history of asthma and allergies and she has a personal history of asthma, allergies, and eczema. She recalls being hospitalized for two days when she was nine years old for an asthma exacerbation. She currently takes Advair and an Albuterol inhaler to control her asthma and she uses triamcinolone cream to treat her eczema. She is prescribed a birth control medication. Her health literacy was assessed using the Short Assessment of Health Literacy tool – English version, on which she scored a perfect score of 18. She seems to have a good understanding of basic medical terminology and her health.
Section Two: The assessment
The following is a detailed report of the interview with my client beginning with questions regarding the Health Perception – Health Management Pattern:
- How do you perceive your overall health?
Answer: Overall, I think I am healthy.
- What current health issues do you have?
Answer: I have asthma, allergies, and eczema but they are all good right now.
- How many times have you missed work due to any of your health issues?
Answer: I haven’t missed work due to any of these issues.
- How often do you use your fast-acting inhaler?
Answer: Most of the time I only use it when I get sick.
- Are you ever awakened by coughing during the night?
Answer: Not anymore, but my mom said I used to always cough at night. That’s why she brought me to the doctor; he diagnosed me with asthma when I was like two years old.
- How many times have you been hospitalized because of your asthma?
Answer: Just once. I spent two days in the hospital because of an asthma attack when I was nine years old.
- Do you know what triggered the attack?
Answer: Yes. It was December and it was very cold out that morning. My teacher took our class out for a walk at the beginning of the school day and I started coughing, wheezing, and having a hard time breathing when we got back.
- It seems then, that exercise and extreme weather are triggers for you? What other triggers do you have?
Answer: Yes, they are. When I was little, and I would laugh or cry hard I would start wheezing and my mom would have to give me a nebulizer treatment. I remember having trouble breathing once when my mom sprayed Lysol in our house. And when I get sick I usually have trouble breathing. Also, in the Spring when everything is blooming.
- How many times have you had to take steroids for your asthma?
Answer: Just a few times.
- How good are you at remembering to take your daily medications?
Answer: I’m very good at that. My mom taught me how to take my medications at a very young age. I’ve been taking them for so long that it is not hard for me to remember to take my medicine.
- Do you have any difficulty paying for your medications?
Answer: No. I’m on my mom’s insurance so I just pay the copay.
- How often do you visit your doctor?
Answer: I go for a checkup once a year and I see him when I get sick or my inhaler isn’t helping my breathing.
- Very good. Do you have any unhealthy habits?
Answer: I smoke cigarettes occasionally, but not every day. But I don’t drink or do drugs. I don’t really eat the best.
- What healthy habits do you have?
Answer: I go to the gym at least a few times a week and I drink a lot of water.
- That’s great. You said you have allergies? What kind of allergies do you have?
Answer: I’m allergic to eggs, nuts, pet dander, pollen, trees, and grass.
- So, you stay away from those things as much as possible?
Answer: I don’t eat eggs or nuts and we always keep the air conditioner on in the warmer months, so the pollen doesn’t bother my breathing. I do go outside sometimes, but then I break out from the grass and stuff and it makes me itch.
- What do you do when that happens?
Answer: I take a shower and use my triamcinolone cream.
- Do you carry an EpiPen because of your allergies?
Answer: No. I have one, but I don’t carry it because I hate needles, so I won’t use it. My mom tried to get me to carry it when I was in high school, but I never would. She said someone else could give it to me if I needed it, but I still wouldn’t carry it. I think I had one in the nurse’s office when I was still in school though.
- You do know that the EpiPen could save your life in the event of an allergic reaction?
Answer: Yes, I know.
Next, I asked questions regarding the Coping – Stress Tolerance Pattern:
- Tell me a little bit about the stress in your life, at work and at home, etc.
Answer: I probably have more stress than most people my age because I have a two-year-old daughter and I’ve had custody issues with her dad and stuff. Being that my daughter is two, she sometimes throws temper tantrums. My daughter and I share a bedroom at my parents’ house so I’m trying to find a house of my own, but I haven’t been able to find anything in my school district yet. I have a lot of stress at work because my boss yells at everyone all the time so I’m looking for a different job. And everyone keeps telling me that I need to go back to school but I don’t want to give up any more time with my daughter than I already do; she’s going to be starting school in two years and she’ll be in dance class and sports and stuff and I don’t want to miss any of that to go back to college.
- How do you relieve your stress?
Answer: I just try to get away from whatever is stressing me out. If it is my daughter, I will put her in her room or put her to bed if it is late. If my boss is stressing me out, I just try to ignore her. Sometimes I go to the gym when I’m stressed out.
- Do you have a support person to go to when you’re stressed?
Answer: Yeah, my mom or my best friend.
The Values and Beliefs Pattern was assessed next:
- What things are important in your life?
Answer: My daughter, my boyfriend, my car, having enough money to buy a house hopefully soon and maybe going back to school but I’m not going to go back to school if it takes time away from my daughter because I already only have her 50% of the time.
- What about your health? Do you think that’s important?
Answer: Yeah, but I feel good and I work out sometimes, so I’m not worried about it.
The additional pattern I chose to ask my client about is the Sexuality – Reproductive Pattern. I chose this pattern because my client is a young, sexually active female who is at risk for STDs and other female issues like pregnancy and breast cancer. Our conversation went like this:
- You mentioned at the beginning of our interview that you take a birth control medication. I’m assuming you are sexually active then?
- Do you think you want to have more children in the future?
Answer: Maybe one more. But not for a while.
- Do you know that if you decide to become pregnant in the future you need to talk with your doctor about stopping your birth control medication and how long you should be off it before you try to become pregnant?
Answer: No, I didn’t realize that, but I will.
- How often do you see your Gynecologist?
Answer: Once a year.
- Are you having any “female problems such as itching or discharge from your vagina?
- Any abdominal pain?
- What concerns do you have about sexually transmitted diseases?
Answer: I don’t know. I mean, I haven’t really thought about that too much, but I haven’t had a lot of partners.
- That’s good. Just know that it is very important to protect yourself from sexually transmitted diseases. The best way to do this, of course, is abstinence, or not having sex, but using a condom can protect you as well. There are other things you can do, too. You should look at the CDC’s website as there is some good information there. Do you perform breast self-exams? (U.S. Department of Health & Human Services, 2016)
Answer: No, not really.
- Do you have any history of breast cancer in your family?
Answer: Yes, my mom’s mom died from breast cancer.
- Having a close relative with breast cancer could increase your risk of developing breast cancer. Performing breast self-exams once a month could help you detect breast changes and/or breast cancer early. You should talk to your doctor about this next time you visit. He or she can show you how to perform the self-exam. Another way to prevent breast cancer is to stop smoking. (Mayo Clinic Staff, 2018)
Section Three: Physical Assessment
The body system I chose to assess that is pertinent to my client, is the respiratory system. I chose this system because it is the one most affected by asthma. The physical assessment that I would perform would essentially begin during the questioning phase and is as follows:
the (Mayo Clinic Staff, 2018):
- I would observe whether my client speaks to me in full sentences or short sentences; short sentences would indicate shortness of breath.
- I would look for accessory muscle use which is common in people who are having difficulty breathing.
- I would observe whether my client is coughing, as coughing is also common in asthmatics.
- I would take notice of her posture because sometimes patients who don’t breathe well tend to lean forward trying to breathe better.
- I would observe the chest for any deformities.
- I would auscultate the lungs and listen for wheezing and/or airway obstruction or high-pitched whistling sounds.
- I would access my client’s heart rate because when people are having difficulty breathing they work harder to breathe which causes their heart rate to increase.
- I would examine the nasal passages for increased secretions, mucosal swelling, or nasal polyps.
- I would observe the inside of my client’s throat for swelling and increased drainage.
Part one, Section four:
In conclusion, I feel that my interviewee’s overall health is very good. She is young and is well aware of the signs and symptoms to watch for with her asthma and she knows what to do when she is having difficulty breathing. She visits her primary care physician regularly and when she gets sick or has difficulty breathing and her inhaler is not helping. She is well aware of what triggers her asthma and avoids those triggers. She stays in the air conditioning when the pollen levels become high. She takes her medications regularly, and as directed and knows how to treat an asthma exacerbation when she has one. She knows she should carry her EpiPen but refuses to do so. Hopefully, she will change her mind as she ages and matures. She admits to having quite a bit of stress in her life but seems to manage it well by exercising and getting away from the sources of stress when she can; she is currently looking for a different job. We talked about sexually transmitted diseases and the use of condoms, but she is not very concerned with this and it is not likely that she will make any changes pertaining to this. We also spoke about her risk for breast cancer, the importance of doing breast self-exams and, also about going off her birth control pills if she decides she wants to become pregnant. he agreed to speak to her doctor about these things at her next visit.
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Part Two – The Career and Industry Research ReportAlthough there are a few areas for health promotion that I identified in my interview, I chose asthma as the priority and I recommended the following health-teaching resources for my client: I located a video series called Asthma Care for Adults Video Series at https://www.pathlms.com/aafa/courses/8092. I chose this site because the video course is free and there are several videos to watch; it is very informative and easy to understand. Next, I chose a section of the CDC website located at https://www.cdc.gov/ASTHMA/faqs.htm. I feel that this is written at a level which my interviewee can understand without difficulty and it explains what an asthma attack is, what causes an asthma attack how asthma is treated. Another health-teaching resource I chose is a pdf that gives information about asthma triggers. It is located at
https://www.lung.org/assets/documents/asthma/avoiding-and-controlling-triggers.pdf. I also found a great video that shows how to clean a nebulizer, which is something I feel that patients probably do not do often enough or even at all. You can find this video at https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/patient-resources-and-videos/how-to-clean-a-nebuluzer.html.
Part three: Reflection
1) My interview/conversation about health, goals, and health behaviors seemed different from a standard medical history interview and assessment in that it was much more in-depth and focused than it normally would be. When doing an admission at the hospital I typically do not have enough time to get that in depth or focused with my patient and sometimes my patients have altered mental status and no one else is present to answer questions about the patient’s health history.
2) My greatest personal strengths in a health promotion interview are that I am calm and nonjudgmental which helps my patients feel comfortable telling me things about their health. The most difficult topic that I spoke with my interviewee about is whether she is sexually active and how to prevent STDs.
3) To keep my interviewee on track and geared toward her interests, I tried to give a response after each of her answers before I went on to the next question.
4) One specific thing I learned in this interview process is that if I want to give my patients a good education about their health I need to try to manage my time better, so I will be able to spend more time with my patients. The more time I can spend with my patients, the more education I will be able to give them.
- Asthma and Allergy Foundation of America. (2017, December). Physical Exam. Retrieved from https://www.aafa.org/physical-exam-diagnose-asthma/
- Asthma and Allery Foundation of America. (n.d.). Video series. Retrieved from https://www.pathlms.com/aafa/courses/8092
- Mayo Clinic Staff. (2018, August 28). Steps in testing and diagnosis. Retrieved from https://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma/art-20045198
- Morris, M.J. (2019, January 7). Asthma Clinical Presentation. Retrieved from https://emedicine.medscape.com/article/296301-clinical
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