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PLEASE RESPOND TO THE FOLLOWING CLASSMATE POST IN 50 WORDS OR MORE:
1) The nurse should proceed with the interview portion of assessment as follows:
Introduction of self and role as a health care provider and the purpose of interview.
Obtain biographical data:
Legal name
Age, birthday, and birth place
Race
Ethnic background
Identify J.P’s perception of health: How do you feel about your current health situation? Do you have any health concerns?
Collect Subjective Data:
Health history/ Dental history
Allergies
Hospitalizations
Operations
Current medication list and adherence to prescribed medications
Family health history
Immunizations
tobacco/alcohol/drug use
Activity level, Functional status (Do you ambulate on your own or with assistance of walker, cane or wheelchair?)
Life stressors and coping
Diet (How often do you eat out? Who provides and makes meals for you?)
cultural values
sexual practice
support system
Collect Objective Data:
General appearances
Body language
Eye contact
Facial expressions
Appearance of home
Vital signs
Hight and weight
In addition to gathering all patient information, it is imperative that the nurse establishes rapport with J.P. so that he feels safe discussing sensitive data in a setting that is free from judgement and discrimination.
During the interview portion the nurse should initiate teaching that is catered to patient’s problem list in order to promote health and disease prevention.
2) The components necessary to complete J.P’s interview are complete and accurate data collection of J.P’s overall health. Establishing trust so that patient feels accepted and open to discuss sensitive information. This allows the nurse to build rapport so that J.P and the nurse can continue to build a therapeutic relationship that will allow the facilitation for further treatment and planning. In addition, teaching J.P. about healthy life style modifications and disease prevention are also important in the completion of the interview.
3) Subjective Findings (Problem List);
Health history- Hypertension (takes metoprolol), Hyperlipidemia ( takes a statin), Afib (on Eliquis).
Does not see a dentist regularly
Family history- heart disease
Diet-eats out 4-5 times per week. J.P does not like to cook.
Support system- No family that lives in state. J.P. is widowed now for 15 years, and daughter lives out of state.
Exercise -J.P. does not like to exercise. Only walks around the house independently and has no hobbies.
Drinks alcohol- Drinks 3-4 cans of beer daily
4) Objective Data (problem list)
General appearance- J.P. looks unkept, long dirty beard, uncombed hair, staines on clothes, malodorous breath and missing teeth, over weight.
Facial expression- Looks tired
Appearance of home- Unwashed dishes in sink, dirty laundry on bedroom floor, smells of soiled linens. Empty beer cans on living room floor.
5) What teaching should the nurse consider from problem list?
Nurse should consider J.P’s overall health status and current life style habits. J.P. has a cardiac history and should consider lifestyle modifications such as establishing an exercise routine and healthy diet. Because J.P. does not have a healthy support system and does not like to cook, the nurse should provide community resources that can assist in meal delivery services and home health aids that can assist with ADL’s and meal preparation and cleaning. In addition, nurse can provide easy and fast healthy meal prep ideas in printed form.
Finding things that J.P. enjoys can also facilitate J.P’s functional status. Things such as gardening, fishing, or building things provides not only physical activity , but can promote mental health as well.
Routine dental check up’s are also crucial for overall health and the nurse should provide information on the importance of good oral hygiene and community resources that provide free or low cost dental services.
Daily alcohol consumption also seems to be an issue in J.P’s overall health. Teaching on the effects of alcohol on mind and body and providing community resources such as therapy would also be essential.
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