Donna S Health Assessment Paper Essay

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Donna

Genogram

The purpose of this genogram is to carry out the health assessment of the client health and wellness. The name of the client is Donna. M, a female patient, aged 49. The patient is a registered nurse, however, her father was no more living, and had been diagnosed with type 2 diabetes when he was 60 years and older before he died. Fig 1 reveals the genogram of the patient.

Fig 1: Donna's Genogram

Her mother is still alive and has been diagnosed with high cholesterol. Moreover, the patient has a living two brothers, two sisters, a son, and two daughters. Her son has been diagnosed with ADHD during her childhood and her daughter has been diagnosed with brain cancer and depression when she was an adolescence.

The maternal grandfather was no more living and had kidney disease when he was 60 years of age. The maternal grandmother had died and been diagnosed with Alzhe/Dementia when she was 60 years and older. Moreover, the paternal grandfather had the unknown disease when he was 60 years and above before he died. However, the paternal grandmother was diagnosed with colon cancer when she was between 50 and 59 years of age and was been diagnosed with type 2 diabetes. She was above 60 years of age before she died. The patient also has a living maternal uncle who has been diagnosed with type 2 diabetes. She also had another non-living maternal uncle who had been diagnosed with type 2 diabetes and Alzhe/Dementia before he died. The paternal aunt is still living with a history of no known disease.

Cultural Influences

Analysis of the health practices of the client reveals that she does not engage in active physical activities. A recommended healthy practice is to engage in at least 150 minutes of physical activity per week. However, the client engages in zero physical activity. The client personal hygiene is excellent based on her ability to clean her hair regularly. Moreover, the client does not smoke, she also cleans her clothes and nail regularly.

Nutrition

The client nutritional status is as follows:

114% of whole fruits

109% of vegetables

80% of refined grains

55% of protein, and 59% of cheese & milk.

Moreover, the client eats excess sugar of 114 g per day where the recommended limit is 50 g per day. The client also eats 5 oz. of grain, 2 1/2 cups of vegetables, 2 cups of fruits, 3 cups of dairy and 5 1/2oz. of protein per day. The risk factor of the client nutritional status is that she takes below-recommended protein, grains, and dairy food per day making her facing the risk of being non-resistance to disease by eating below the target daily calorie limit. (Jarvis, 2012).

Individual Client Profile

Biographical Data

The client was 49 years old female patients, married with three children (two daughters and one son). She is a Caucasian, an American citizen, and a nurse by profession.

Past Health

The patient past medical history reveals that she is suffering from obesity with the history of hypertension. Although the patients do not smoke, however, her vital sign are:

Weight -- 160 pounds

Height -- 5'1"

Body mass index -- 30.23,

Vision Snellen eye chart:

Right eye -- 20/30,

Left eye -- 20/40.

Respiration -- 20, 4:1

Blood pressure

Right arm in a sitting position -- 165/110

Left arm in a sitting position - 170/115

Temperature -- 98.2 F

Pain assessment -- a headache

The patient has also been diagnosed with gestation diabetes when she was between 30 and 39.

Functional Assessment

The client likes eating a regular biscuit, baking powder, and buttermilk of 67 calories a day. Moreover, the client has a habit of taking snacks such as chocolate, cookies and vanilla sandwich reaching the 190 calories a day. She also likes taking ice cream and chocolate that reach 428 calories a day. Additionally, the client like eating milk, and chocolate bar reaching 235 calories a day. However, the patient does not indulge in active activity revealing that she faces the risks of hypertension, diabetes, and cardiovascular disease. The assessment of the patient reveals that there is an interpersonal relationship between her and the immediate family. (Jarvis, 2012).

Perception of Health

Donna is a registered nurse and aged 49, Caucasian, a nurse by profession.

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The patient weighs 160 pounds, and height 5.1." The body mass index is 30.23 and has three children with a living mother and non-living father. The health assessment of the patient reveals there was a history of diabetes in the family because her father was diagnosed with type 2 diabetes. The patient has also been diagnosed with gestational diabetes, and her non-living uncle has been diagnosed with type 2 diabetes. Moreover, there is a history of Alzhe/Dementia in the family. Additionally, the client does not engage in active physical exercise making her facing the risk of hypertension. The nutritional characteristics of clients are whole fruits, vegetables, refined grains, protein, cheese, and milk. However, the client has the habit of eating vegetables, dairy, fruits, and protein making facing the risk of being non-resistance to disease by taking food that is below the target daily calorie limit. However, the client likes eating a biscuit, buttermilk, and baking powder. She also likes eating cookies, chocolate, vanilla sandwich, ice cream, and milk.

Physical Examination

General Appearance

As being stated in the previous section, the patient's age is 49, however, the client skin color is light red with aging spot. The patient also uses the assisted devices for the movement. Moreover, her facial expression is symmetrical with comfortable eyes contact. Her mood and her spoken English is appropriate to her level of education and age. Moreover, her hearing is 100% with no makeup.

Measurement

Her weight is 5.1" with height 160 cm. The body mass index is 30.23. Her vision with Snellen eye chart is as follows: The patient wears glasses for the correction of Left eye -- 20/40 and Right eye -- 20/30. Her respiration measurement is 20, 4:1. Her blood pressure of the right arm at a sitting position is 165/110 and left arm in sitting position is 170/115. The measurement of her temperature is 98.2 F making her have a headache.

Head and Face

Her hair is light brown and curly. Her face looks oval and symmetrical. Her temporal artery is visible. Moreover, the movement of the temporomandibular joint is normal with no tenderness. Her frontal joint is firm and experience no pain.

Eyes, Ears, Nose, Mouth (level 2 heading)

The patient wears glasses to view all periphery. Moreover, the external structures of the client are parallel to one another. Her conjunctiva is transparent with visible underlying and tiny blood vessels. Moreover, her cornea is smooth with clarity. Her Irish is regular with even coloration. The pupils are blue, equal and regular in both eyes. Moreover, the color of her disc is creamy yellow in color with an oval shape. The artery of her vessels is brighter than a vein. Based on her retinal background, each of her eyes has a pair of veins and arteries. The A: V is 2.3 and asymmetry in the left eye. (Houghton, & Houghton, 2009).

Moreover, the patient pinna is bilateral with no swelling, no lesions, and no thickening. More important, the voice test shows that the patient repeats the whispered word. The nose test shows that her external nose is symmetrical, smooth stable and firm. The patency of the client is clear, no swelling and no polyps. The patient lips are pink, moist and smooth. The teeth are white, clean and free of debris. Her gums are pink in color, and margins are tight with no odor. The tongue has pink color with the presence of saliva. The client tonsils are visible, no exudate with 1+. The Uvula rises, the cranial nerves IX, X, rises in the midline. Her tongue, the cranial nerve XII, protrudes in the midline, no deviation to the side and no tremor.

Neck and Neck Vessels

The neck of the patient has the symmetrical pulsation feature with no lumps. There is no indication of enlargement and tenderness. Her pulse is smooth, moderate and no presence of bruits. There is also no masses and tenderness in her trachea. Moreover, the patient does not experience pain in the muscle of the neck with normal movement from head to shoulder, chin to chest with full ROM resistance.

Chest, Posterior, Lateral, and Anterior

The test reveals that the thorax of the patient is symmetric with downward sloping ribs. Moreover, scapulae are located symmetrically within each hemithorax. There is no cyanosis and no.....

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