1. 2. Identify the components included in a client’s health history. Biographic Data-The client’s demographic data, should include the name, address, age, sex, marital status, occupation, religion, health care financing, and primary care provider. Chief Complaint-The reason for the visit should be obtained and documented in the client’s own words. History of Present Illness-Gather more information about the present illness by asking questions such as: When did the symptoms start? Did it occur suddenly or gradually increased over time? How often does the problem occur? What is the intensity of the pain? Can you rate it from 0 to 10? How much sputum, vomit, or discharge came up or out? What color was it? Was it watery, thick, or bloody? …show more content…
Moreover, diseases that require particular attention includes: heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and mental health disorders. Lifestyles-Ask the client about their personal habits such as the amount of tobacco, alcohol, caffeine, or recreational drugs consumed. Also, obtain their normal daily diets, special diets, or ethnic food patterns; and the amount of meals and snacks per day. Likewise, who cooks and do the shopping? In addition, ask about the client’s sleep pattern. What time do you go to bed/ what time do you wake up? Any you having any problems sleeping? Have you tried anything to correct this problem? Furthermore, ask about the daily living activities. Are you having any problems performing basic activities such as eating, grooming, dressing, elimination, or locomotion? Are you having any problems with preparing foods, shopping, transportation, housekeeping, laundry, or the ability to use the telephone, handle finances, or manage your medication. Finally, ask the client do you exercise and how well do you tolerate the activity? Do you have any other hobbies? Social Data-Ask the client who helps them during times of stress? What effects have your illnesses had on the family and are there any family problems affecting your illness? Do you have any religion or beliefs that could affect your health or recovery? Moreover, find out about the client’s education. What is
A sound understanding of the general outline of the clients health and fitness can give you a better
The client is more than the patient I am caring for on the unit. It extends to the family, caregivers, and friends. When working with complex patients, I remind families they are the “expert” on the patient. They feel valued knowing their information and input is
To effectively provide health care services to my patients, I undertake to listen to issues raised by patients and their relatives. During the process of interacting with my clients I will first of all introduce myself to
As stated by the World Health Organization (WHO), ‘health’ is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948). The health and wellbeing of individuals is generally determined by their circumstances and environment, a phenomenon referred to as the social determinants of health. WHO describes the social determinants of health as:
Health teaching will be providing information on disease process and management strategies. Encourage caregiver to set aside time for himself. This could be as simple as a relaxing bath, a time to read a book, going out with friends. Acknowledge to caregiver the role he is carrying out and its value. Teach caregiver to identify how important it is to feel appreciated for their efforts. Encourage care recipient to thank caregiver for care given. Provide time for caregiver to discuss problems, concerns, and feelings. Ask caregiver how he is managing, Inquire about caregiver’s health. Refer to social worker for referral for community resources and/or financial aid, if needed.
Clients are assessed in a holistic way to identify the needs and therefore to provide individualised care plan. For instance, people unsteady on feet might need minimum support in personal care under the provision of safety as well as maintain their independence. Some with poor vision accuracy might require assistance in medication management due to the high risk of error in medication administration. Besides, chronic conditions have profound negative impact on individual’s life such socialisation (Carrier & Newbury 2016). Social isolation could further impact on physical and mental health. Nurses can address this issue by teaching clients to understand their conditions and work with them to set goals for long-term management. Nurses could also empower them to participate in the community programs such as craft workshop and bus trip. Individual’s socioeconomic position, employment, education, housing and other resources influence one’s health and wellbeing (Marmot 2005). I have come across clients from various cultural backgrounds. As a community nurse, I also need to understand client’s culture needs, family structure, and cultural norm, by addressing their preference and the language barriers. These barriers may prevent clients from seeking relevant services if they do not
I will now talk about each patient needs as they all differ from each other. Nusrat Patel is 19 years old and has learning disability. This means Nusrat has difficulties in keeping knowledge and skills to the expected level of those the same age as her. Nusrat also has epilepsy which is neurological brain disorder when someone has epilepsy, it means they tend to have epileptic seizures, a seizure is a sudden attack of illness. Nusrat has left residential school to receive full time carer from her mum who has stopped working to care for Nusrat. At times this can be stressful so Nusrat attends the community centre on Tuesday and Thursday which allows Nusrat mother to have a break. Maria montanelli is 34 years primary school teacher who is much like Nusrat mother and takes care of her 96 years old mother who has dementia. Dementia is memory loss and difficulties with cognitive development. Being a primary care for her mother Maria feels she not performing at her best ability because of her lack of sleep which occurs when she assists her mother to the toilet several times. The last patient I would like to mention is Alice Fernandez she is 74 years old who recently lost her husband who had lung cancer. Alice doesn't use her pension the right way as she purchases many drinks as an alcoholic and has increased since her husband passed away. She has been prescribed antidepressant tablet by her G.P but made her lethargic this means she's become slow and sluggish.
* Cancer, Heart Disease, Unintentional Injury, Lower Respiratory Disease, CVA, Suicide, Alzheimer’s, Diabetes, Liver Disease, and Influenza/Pneumonia (El Paso County Health
The first questions asked the family about their perceptions of their own health and about what
Women are subservient to males, and males may be dependent on the female of the household. There is a high incidence of alcohol abuse among men. Adolescent children are often less mature for their age. Family and friends should be allowed to remain with a dying patient, and organ donation is viewed as helpful to others. The belief that nothing new happens today that has not happened in the past may affect what illness/sickness leads people to seek health care. I should maintain a distance appropriate for care delivery and investigate health care beliefs or practices. Monitor for signs and symptoms of safety issues within the family unit. Do not assume that maturity is linked to age. Provide time and space for family to be with hospitalized family
What chronic diseases do you see most often in your patients? What is the prevalence rate for the chronic disease you have identified in your practice? What illness behaviors do you see in your patients? Is this typical behavior according to your text? How do their family members react?
The first area outlined in the intake form is the client’s demographic information that included the client’s date of birth, social, insurance information, etc. necessary to process claims for reimbursement and the client’s provider information, such as primary care, and case management, to ensure fluidity for establishment of coordination of care between providers. The intake form
Though this form is extensive, it does appear to cover everything a social worker may wish to know about their client. Despite knowing the importance of a client’s history, it is also important to know when to fine tune a form to get better information. For example, a client may start of answering the questions but then become frustrated and bored. This could lead to inadequate answers for the rest of the questions or inaccurate information. With this form, there are so many questions that one can easily become frustrated and overwhelmed and not answer the questions completely. Even worse, they could skip over the very important questions such as medication history or dug use
The client has a family that she deeply cares for manages. This will be useful for her motivation to get the help they require while adjusting to America
Presenting problems: These are the “symptoms” or the experiences (added or removed) from the person’s everyday