Health History Assessment for Student Nurse: Insights and Reflection

Abstract

Institutional Affiliation: Health History Assessment and Reflection Health History Assessment Demographic The demographic information of the patient provides an overview of the expected health issues they may encounter and the care needs they could expect. For instance, the age and gender of the individual could determine the approach of care adopted by nurses at health facilities. The interview was a 22 year old female student nurse (Kaakinen et al., 2018). At the time of the interview, she was single and had visited the healthcare facility for purposes associated with an annual physical examination. Perception of Health At the time of the visit to the health facility, the patient demonstrated constant migraines that had affected her comfort. She has trouble sleeping and indicated that she experienced stress occasionally. The interview had visited the facility for a physical examination and it was a year since she had the exam. She had physical exercise at least six times a week and did not demonstrate symptoms of reproductive health problems. Past Medical History The past medical history of the patient is critical in dealing with her present conditions and providing the appropriate medication. The interviewee does not have a terminal illness or any identified allergic reaction to drugs or medication at the hospital. She reported having no drug abuse problems such as challenges or engaging in risky behavior after consumption (Nibbelink, & Brewer, 2018). The interview demonstrated that the patient was sexually active and did not have problems related to intimate relationships such as violence. While the interviewee was not in a physically recommended diet, she reported to be a pescatarian, a diet that excludes meat but includes fish. Family Medical History By examining the medical history of a patient’s family, nurses can offer better care and determine the issues that could affect the individual. The mother and the father of the interviewee ere both healthy and were 55 years old each. She reported that her 27 year old brother was healthy as well (Kaakinen et al., 2018). Her grandparents were above 85 years old and had chronic illnesses. The maternal grandmother had respiratory health issues while the grandfather lung cancer. Additionally, her paternal grandmother had thyroid cancer and the grandfather has had a heart attack. Review of Systems Body systems may indicate the possibility of current and future health issues likely to affect patients at different ages in their lives. During the assessment, it was noted that most of the health systems of the patient had not experienced any serious issue in the past. However, she indicated skin/hair/nails and head/neck health problems that occurred prior to the current interview. Developmental Considerations At the time of the interview, the patient was in her early 20s and living with family members. She demonstrated signs of belonging to a supportive family that was determined to meet her immediate and long-term needs at home. Additionally, the patient was attending nursing school at the time of the interview (Nibbelink, & Brewer, 2018). There were no alarming issues concerning her developmental health and the impact on care needs. However, occasional stress could demonstrate underlying challenges with relationships. Cultural Considerations During care, the cultural background informs the nurses the needs to consider sensitive aspects of care that arise in different communities. The interviewee was Vietnamese and her Asian culture could affect the care nurses provided to her and their interaction with family members (Shahin, Kennedy, & Stupans, 2019). In this culture, healthcare is significantly oriented towards family members and group support. When caring for the patient, it would be critical to consider the involvement of family members whose input is deemed necessary in meeting the patient’s needs. Psychological Considerations While the interviewee reported to have had incidents of stress, she was emotionally and mentally health. She had not had a major incident of depression, drug, or alcohol abuse in the past. Her drinking was described as once every other week indicating that she did not have an addiction. Additionally, the interviewee was observed to be receiving emotional support since she was residing alongside other individuals in her residence. Collaborative Resources Developments in healthcare have focused on the measures through which care providers could work towards meeting the needs of their patients. Information sharing among nurses is critical in facilitating the provision of quality...