Health History
Introduction
Health history assessment is a vital part of the nursing process. This process establishes the foundation through which nurses can diagnose and create a care plan for their patients. That said, incorrect health assessments may result in misdiagnosis, hence wrongful care plan development. For this task, I interviewed Anna, L. (not her real name). The following discussion encompasses a review and reflection of this interview.
Demographic Data
Anna is a 26-year-old single female of Japanese descent. She recently moved to the US to pursue her degree at the University of Illinois at Chicago. Her hobbies include traveling, photography, blogging, dancing, and cooking. Anna stays with her aunt and uncle in one of Chicago’s middle-class residential developments. However, her immediate family, comprised of both parents and her 22-year-old brother, lives in Japan.
Perception of Health
In the traditional Japanese culture, one would consider the oldest member of their family as a representative of the family’s understanding of health. Anna’s extended family in the US have a positive regard of western medicine. However, the family still respects the healing capabilities of traditional medicine, among them Japanese herbal teas. These views make her moderately open to suggestions on occasional visits to the family physician. Also, they have little or no regard to issues concerning mental health. As a result, Anna finds it irrelevant to discuss symptoms related to depression (Lee, et al., 2009).
Past Medical History
Anna has received vaccinations for BCG, PCV, MR, Japanese Encephalitis, DTP-IPV, HPV, Chickenpox, Hib, and Hep A and B. She denies current symptoms of a primary disease. However, she had past encounters with typhoid fever, flu, diarrhea, malaria, cuts and burns, migraines, and depression. That said, Anna recalls receiving treatment for all conditions except depression.
Anna admits to finding it hard settling in the country and its school system. She recalls that there are times when she remembers and misses her immediate family back in Japan. Anna further reports feeling depressed weeks before she left Japan for the US. This incidence occurred following a breakup with her long-term partner, who could not commit to a long distance relationship. Though she denies any suicidal ideation after this incidence, Anna admits to suffering from sleeplessness, loss of appetite, and worthlessness. She also denies any significant traumatic event or obsessive behavior (Jarvis, 2015).
Family Medical History
Though unsure, Anna does not believe there exist serious medical conditions in her family. She viewed both of her parents as, on overall, healthy, although her father has diabetes. She describes her 22-year old brother as of excellent health. However, in 2010, Anna’s paternal grandmother suffered from the stroke after the death of her grandfather to old age. Finally, Anna reports that her maternal grandmother is psychotic while her maternal grandfather remains healthy.
Systems Review (Head-to-Chest)
Integumentary Assessment
Skin: Anna’s skin is visibly uniform in color and soft to touch.
Hair: Her hair is long, dark, and free flowing. There are no signs of infection upon observation.
Head
Head: Anna has a balanced and symmetrical head.
Skull: No depressions and nodules upon palpation
Face: Her face appears uniform in color with no visible signs of blemishes.
Eyes
Eyebrows/lashes: Anna’s eyebrows and eyelashes are dark in color, symmetrical and evenly distributed.
Eyelids: There exist no presence of lesions, discharge, or discoloration. Anna’s lids blink involuntarily about 16 times per minute.
Eyes: Wears glasses, admits to being short sighted. Nonetheless, her pupils are reactive to light, equal, and rounded. Her conjunctiva is pink without any exudates.
Ears
Auricles: Anna’s auricles are both symmetrical as well as have a similar color with her skin. They are firm and mobile upon palpation.
Pinna: Her pinna recoils when folded and released
Hearing: Uniform for both ears.
Nose
Symmetrical and uniform in color.
No signs of nasal discharge
Mouth
Lips: Her lips are symmetrical, pink, and moist. Anna can purse her lips and blow a whistle.
Teeth and Gums: Her teeth are white and gums uniformly pink and moist. No signs of discoloration.
Tongue: Assumes a central posture, pink, moist, and signs of a thin whitish coating.
Uvula: Centrally located on the soft palate. Moist and pink in color.
Neck
Neck muscles are well-coordinated and equal in size. Anna shows no signs of discomfort upon movement.
Thyroid non-palpable; absent lymphadenopathy; trachea at midline.
Breast
Deferred assessment
Thorax
Chest: Chest wall remains intact with no visible tenderness. Full expansions visible. Anna manifests effortless and rhythmic respirations in response to percussion and auscultation.
Heart sounds: RRR; Normal S1 and S2; Absent S3 and S4.
Spine: Shows vertical alignment
Shoulders: Both shoulders are symmetrical to the trunk
Developmental Considerations
Anna is at a stage in life where one grapples with Intimacy versus Isolation. At this juncture, she can either prefer isolation or seek companionship family, friends, and romantic partners. Anna has had a stable and fulfilling relationship with members of her immediate and extended family. However, a recent break-up with her long-term boyfriend as well as movement from Japan to the US may set her up for psychological issues. That is, given her new life, Anna may find it hard to reestablish committed relationships unless she resolves her residence and romantic issues.
Cultural Considerations
As seen above, Anna stated that culture plays a significant role in influencing her health belief system. This influence would touch on critical areas such as health-seeking behavior, trust in western pharmacological interventions, diagnosis, and adherence to treatment. Furthermore, Anna’s extended family has a huge influence on her view of health and healthcare system. In essence, Anna sees her uncle as her primary decision maker for her healthcare needs of the United States. Nonetheless, she has a good command of English and feels she is on the right path to full acculturation to the American culture.
Psychosocial Considerations
Anna is a 26-year-old single woman, who recently moved to the US from Japan for her studies. Though her immediate family remained in her homeland, Anna stays with her aunt and uncle in Chicago. Though she is relatively new in the country, Anna has already found a friend and can count on her extended family for social support. Currently, there is no one in the household with an illness grave enough to affect her daily life in the US.
Nonetheless, her grandmother’s psychosis has taken a significant toll on the extended family. Also, though born a Shinto, Anna does not consider herself as religious, thus pays limited attention to meditation and prayer. She claims to be open to active forms of healthcare out of her family’s respect for health. Finally, though she misses her family and ex-boyfriend, Anna intends to stay in the US, find a job and become a citizen.
Priorities for Physical Assessment
I realize that Anna is at risk of depression. Therefore, I would prioritize an evaluation of Anna’s general vitals, skin, head, and ENT. The clinical manifestation of depression includes suicidal idealization, self-worthlessness, persistent migraines, loss of interest and loss of appetite, sadness, as well as insomnia. Her depressive tendencies would occur following an interplay of a variety of factors including social, environmental and familial causes. As seen, maternal grandmother suffers from psychosis. Also, thoughts of her family and former boyfriend might act as stressors to Anna’s depression (Lee, et al., 2009).
Teaching need Priorities
Collaborative Resources
The three collaborative resources that apply to Anna’s case include her extended family in the US, friends at school, and her view of the current healthcare system. These entities are influential in determining Anna’s approach to western medicine. They are also vital in changing her health seeking behavior concerning mental health. In essence, she could find support on handling the social strain associated with depressive disorders.
Reflection
Anna and I selected Friday afternoon as the perfect day and time for out interview. A mutual friend and a classmate of hers had introduced us with the view that I would gain exceptional experience interviewing a recent immigrant. We met at a local coffee shop and got to introductions before beginning the formal interview. I could sense that Anna was shy about the conservation from the way she kept looking down at the onset of the conversation. However, I calmed her down through positive talk and occasional jokes (Jarvis, 2015).
Throughout this interview, I learned that culture is essential in determining an individual’s healthcare belief system. This experience compares to what I have learned in school concerning the importance of a holistic approach given patients from a diverse pool (Jarvis, 2015). The ideal cultural encounter offered a chance to develop the clinical skills required for streamlined cross-cultural interactions with culturally diverse patients. My direct interaction with Anna helped me advance my cultural competence when faced with holistic patient assessments. Eventually, I was able to connect Anna’s story to her present and future healthcare requirements (Augsberger, Yeung, Dougher, & Hahm, 2015).
The biggest barrier to communication exists in trying to navigate through Anna’s Asian accent. However, I took a slow approach to communication, allowing her to speak as slowly as she could. Also, I encouraged her to use the most Basic English vocabulary. In future, I will consider having a close friend accompany my respondents when dealing with such patients. Finally, it would be vital to engage professional translators in cases that involve non-English speaking patients (Lee, et al., 2009).
The unanticipated challenge linked to this interview focuses on that short time taken to go through the interview. I figured that we would have enough time to discuss, considering the day and time selected for the meeting. However, I had to be time-conscious because Anna had to run some errands. Nonetheless, I wished I would have obtained additional information on the role of religion in palliative care, especially with Anna’s maternal grandmother’s condition. Finally, I will consider a more inclusive approach when dealing with questions on how extended families cope with terminally ill patients (Flowers, 2004).
References
Augsberger, A., Yeung, A., Dougher, M., & Hahm, C. (2015). Factors influencing the underutilization of mental health services among Asian American women with a history of depression and suicide. BMC Health Services Research 15:542, 1-11.
Flowers, D. (2004). Culturally Competent Nursing Care: A Challenge for the 21st Century. Critical Care Nursing, 24 (4), 48-52.
Jarvis, C. (2015). Physical Examination and Health Assessment. Maryland Heights, Missouri : Elsevier - Health Sciences Division.
Lee, S., Juon, H., Martinez, G., Hsu, C., Robinson, S., Bawa, J., & Ma, G. (2009). Model Minority at Risk: Expressed Needs of Mental Health by Asian American Young Adults. Journal of Community Health, 34 (2), 144-152.
