Case Study: Health History Assessment


In response to (D’Amico, 2011), well being evaluation to be a affected person means the systematic approach of amassing consumer’s knowledge, with an intention of figuring out his/her present well being standing, the well being threat they could be uncovered to, and figuring out the well being apply actions to be executed to enhance the affected person’s well being standing. It may possibly additionally consult with the intentional and interactive course of by which nurses critically gather, and analyses and digests the related collected info kind the affected person to guage their the standing of their well being. On this essay, I shall current a well being historical past evaluation on an outdated aged affected person and due to this fact there would be the must make use of Complete Well being Evaluation (CAH), which is a scientific apply related for the aged sufferers. (Agedcare, 2013), states that the aged are uncovered to extra delicate medical and social points by way of the care necessities, due to this fact requires Complete Well being Evaluation, that ensures expert workers that can guarantee care to the affected person. My affected person was aged Ms. Pamela Jackson, and due to this fact, for the evaluation, I used to be inquisitive about demographic knowledge, the affected person’s notion on well being, previous medical historical past, each for the affected person and the lineage household, and another details about the affected person.

Demographic Information

The demographic knowledge in an evaluation embrace the start yr, the gender, nation they arrive from and if there are, many ethnic teams then which one does the affected person belong. Ms. P.Ok was 86 years outdated by final yr after I assessed her. She is presently dwelling in New York however she was born in South Carolina. Pamela lives in third ground, on a narrative constructing however used an elevator, in a one-bedroomed home, and her kids helps her monetary, whereas for social safety and Medicare she receives kind the federal government.

Notion of Well being

World Well being Group (WHO) (2014) defines well being because the state of being mentally, bodily, and socially effectively and it's not merely the thought of not having any illness. On this case, the aged normally don't really feel comfy as they really feel lonely, with no person with them to assist them undergo. The affected person describes the ache that she goes via when the chest ache begins and hopes that issues may have been totally different if she had been wholesome. The affected person loves different actions, and usually nonetheless robust when she feels wholesome. She may go to the farm, stroll her canine round and after these actions she may loosen up. Pamela normally feels that the chest pains and these sicknesses usually takes this enjoyable away from her, and normally really feel unhealthy about it. She sometimes feels that she is already outdated and due to this fact, she doesn't should endure that approach as a substitute she will die. Feeling of social disconnectedness from the opposite members of the family who she can't go to usually, nonetheless, someday they make really feel wholesome and cherished. Due to this fact, Pamela says that these days she loves her life and has a change of notion in the direction of being wholesome.

Previous Medical Historical past

In 1964, she had some surgical procedures executed on her, the primary one concerned, complete belly hysterectomy that included the elimination of uterus together with the cervix, this surgical procedure is completed for girls via their vaginas when they're confronted with situations such endometrial hyperplasia, uterine prolapse, or cervical dysplasia. This was extremely related for Pamela as a result of she was affected by dysplasia. 5 years later, she had one other surgical procedure, bunionectomy. One of these surgical procedure helps within the elimination of bunion, which is an enlargement skilled on the joint base of an enormous toe and it's usually comprised of the delicate tissue and the bone. Pamela was experiencing irritation on her legs by then, and he or she had no becoming shoe, due to this fact had undergo with surgical procedure (Bunionectomy, 2000).

The identical yr that she had bunionectomy, is identical yr that she was identified with hypertension, and this was the time her issues began. She was administered some medication that presently she bear in mind which of them, however she will take into consideration is that she stopped utilizing them after three months as a result of they'd a facet impact on her physique, as they had been inflicting drowsiness to her. Some years later, she was identified with peptic ulcer illness, however for this she was administered particular medication, and that's, cimetidine that helped her resolve the issue inside four months’ time. Pamela doesn't have historical past of different sicknesses resembling coronary heart illness, lung illness, nor most cancers.

She had allergy symptoms when she was administered penicillin again in 1965; the medication induced rashes on her physique and hives. Due to this fact, she is often suggested to not use penicillin or for use on her by another medical specialist. She even have a social historical past of utilizing alcohol, she has two beers each weekend with some wines when having dinner. She had no prescription for unlawful drug use, as she by no means used tobacco associated medication.

Household Medical Historical past

Pamela didn't have the prospect to develop up within the care of her mom as she died on the age of 40, leaving Pamela very younger, that her aunt determined to take of her till she grew outdated. The reason for demise for her mom was kidney failure. Her father can be deceased, and the reason for his demise was a coronary heart assault, that stroke him and he was gone. Pamela has been feeling that alone as her husband died too, he suffered from pneumonia and seizures. The outdated girl doesn't have any sisters, however was blessed with 4 daughters who're all effectively, however the son additionally died and was affected by pneumonia. Her household due to this fact has a historical past of hypertension however no diabetes or most cancers. Her members of the family should not have any behavior of alcohol use or people who smoke solely use alcohol throughout events.

Overview of Techniques

Ranging from the highest of her physique to the underside, she was interviewed on how she feels about each half. The usual physique power of the physique ought to good, the load secure at 160 Ibs, and the usual top 5’eight”2. Given the age of the affected person, her eyesight started to be blurry and this required her to put on studying glasses, however she has no diplopia or another eye ache. The age Pamela makes her earing capabilities decreased, and due to this fact, for thus a few years, she has been experiencing listening to loss, therefore she has to make use of listening to assist. Nostril: she has no historical past of tonsillectomy, and has been carrying full set of dentures for a few years and it has been working effectively for her, she has had no obstruction. She has no historical past of pleurisy, bronchial asthma, or coughing in her respiratory programs.

By 1960, she was admitted of hematemesis and melena, which suggests vomiting of blood and discharge of black stool with blood (Wilson, 1990). Her endoscopy confirmed some proof of gastritis and due to this fact acquired items of packed cells; this helped make her stool brown. Pamela has had a historical past of cystitis, E Coli, however was handled utilizing Bactrim. She had 5 pregnancies, with 4 profitable and one miscarriage had her menopause on the age of 50. When it comes to neuromuscular half, she skilled osteoarthritis on the shoulder, hips, and all of her knees for at the very least 20 years. Pamela didn't have histories of hysteria and emotional misery, melancholy, no blood clotting.

Developmental Issues

In response to (Hoffman, 2001), growth is a element within the healthcare throughout all of the lifespan; due to this fact this provides benefit to the healthcare professionals to handle their purchasers. Erickson states that in every stage of growth there are totally different duties that needs to be thought of and this make sure that a person experiences a normalized psychological growth. The eight phases, on condition that Pamela is over 65 in age, she belongs to Ego Integrity vs. Despair.

When it comes to bodily growth, there may be elevated vulnerability to ailments, and this led to the affected person experiencing many sicknesses resembling chest ache and aching joints throughout. The aged usually expertise modifications resembling integumentary together with sagging, wrinkling; musculoskeletal modifications together with lack of elasticity within the joints; metabolic charge declines and different modifications that usually cut back the pleasure and ego of the aged. Due to this fact, they generally really feel deprived by their age.

The affected person had retired way back and due to this fact has the problem of feeling despair, as he lived in a room alone, with the bodily challenges she may transfer round as she used to when she was younger. There may be decreased earnings for the consumer as she had retired. Lastly Pamela has lived for; lengthy and due to this fact have gone via unhappy interval when the members of the family dies and reside her nonetheless alive.

Cultural Issues

The affected person is an American belonging to the Caucasian ethnic group. She has lived in the USA entire her life with none histories of migration to different international locations. She resides in New York and fluent English speaker. She loves to look at motion pictures and take heed to some old-fashioned music with the intention to keep away from having extra coronary heart assaults because of her standing. She is a retired nurse, with low-income sources and is determined by the federal government for social safety and Medicare, and a Christian who doesn't have loads of cultural consideration and due to this fact, provides a simple time to the healthcare professionals.

Psychosocial Issues

Pamela understands her state of affairs however the most effective factor is that she lives with one in all her daughters to assist her undergo the experiences. Nevertheless, the affected person is a really lively persona; that is even though she has the arthritic signs. She acknowledges and already accepts the center assault she usually have, however typically this makes her very anxious as she retains on questioning the second it should strike her once more.

Bodily Evaluation

On account of her mixture of chest pains and the center assaults, I might critically assess her coronary heart functioning and the lungs too. There needs to be a cautious monitoring of the growing chest pains and coronary heart assault, this can be a proof of myocardial infarction and due to this fact needs to be admitted for extra checkups. The affected person’s ldl cholesterol must also be monitored and due to this fact needs to be suggested to have sufficient bodily workouts however mild ones, to make sure free-flowing blood circulation. Some drugs resembling HMG Co-reductase needs to be administered to cut back the ldl cholesterol stage within the physique.

Want Priorities for the Affected person

There are lots of aged individual on this planet who're confronted with such challenges of coronary heart assault and have chest ache as they proceed to get older. To prioritize the wants, there needs to be evaluation and screenings of the center capabilities of those individuals, and a few schooling that's associated to the hypertension in outdated age and the way they will undergo the matter. The one troublesome half right here is the information that some kinds of meals that they must keep away from, such because the fatty meals. They need to be consuming principally greens with decreased sugary contents and a few workouts.

Collaborative Recourses

The primary collaborative useful resource for the affected person can be church, the place she may meet different family and friends and really feel cherished and cared for. Due to this fact, she is not going to need to really feel lonely in the home and alone too. The following useful resource is the members of the family like her daughter and grandchildren coming over to provide her a go to on the dwelling. Doing a little, workouts could be one other useful resource serving to her to extend the center beat and circulation of blood.


The interview passed off within the room of the interviewee, I ensured that her daughter was not round in order that we may have free atmosphere for her to reveal every thing to me. I first assured her of confidence with the data and that it might assist to enhance the healthcare of the aged as she is. The strain between us decreased the extra I used to be asking questions, due to this fact we may talk freely.

Throughout my time with Pamela, it helped learn the way essential well being evaluation was to the sufferers, principally to the fragile aged, who normally really feel exclude in most societies. I realized the well being dangers that the aged undergo and may now have suggestions on the right way to remedy their issues. A few of the obstacles I had had been the issue of insecurity with the data, in a approach the interviewee at instances didn't present all the data related for this evaluation. Nevertheless, the extra query she developed the arrogance and was capable of open up.


Agedcare. (2013, October). Complete well being evaluation of the Older Individual. Retrieved from Division of Well being:

Bunionectomy. (2000). Retrieved from Encyclopedia of Surgical procedure:

D’Amico, D. a. (2011). Cilinical Pocket Information for Well being an Bodily Evaluation . Nursing Creator Donita D’Amico, 36-38.


Wilson, D. (1990). Hematemesis, Melena, and Hematochezia. Retrieved from NCBI: