My case study is on a patient by the name of LaToya. LaToya is a fifty-one year-old black female. She was admitted to the medical-surgical department where I work, with a diagnosis of exacerbation of chronic obstructive pulmonary disease. She has a 66 pack-year history, meaning she smoked the equivalent of 365 packs of cigarettes for 66 years, and occasional drug and alcohol use. LaToya is divorced and lives alone in an older apartment building.
Chronic obstructive pulmonary disease (COPD) is a lung disease that limits your airflow. COPD may include chronic bronchitis, emphysema, or both. Chronic bronchitis is the production of increased mucus caused by inflammation. Bronchitis is ...view middle of the document...
History taking allows nurses to gain a better understanding of the patient’s’ problems, and helps the nurse identify the most appropriate interventions to improve patient outcomes. (Fawcett & Rhynas, 2012).
Developmental age or stage will impact my strategy for obtaining a health history. When patients are developmentally not able to communicate their own health history, I rely on their parents or care takers to give us an accurate health history. This can also be true when interviewing an elderly adult who seeks medical care. The older adult may be forgetful or slower to respond. I may need to rely on others to fill in the gaps in the health history. The objective data is the information from physical assessment and test results.
Subjective Health History of LaToya
The first question of the illness history should be the patient’s chief complaint, followed by the history of that complaint: What brought you into the hospital today? When did you first notice these symptoms? Are there any associated symptoms? Are there any factors that make the symptoms better or worse? This information may guide me to ask additional questions. What treatments, medications, including over-the-counter medications, and vitamins are you currently taking? How is this illness affecting your activities of daily living, dressing, cooking, chores around the house, and shopping? This question may give me clues about the patient’s ability to care for themselves, and the need to ask additional questions. I would ask the patient to discuss your overall general health, including past illnesses and hospitalizations. Also, are you allergic to anything? Do you have a regular physician for routine exams and follow-up? Do you follow the recommendations of a provider? If no, what prevents it?
Psychosocial and Spiritual assessments include assessing the patient’s belief system to oneself, others, and a higher spirit. It includes variables that influence one’s lifestyle and mental health. Do you have religious and spiritual preferences? Who would we contact in case of an emergency? What is your living arrangement? What is your occupation? Do you have a hobby? What kinds of leisure activities do you enjoy? Any cultural or spiritual concerns regarding your care that you would like to tell me about?
Next, I should assess LaToya’s usage of cigarettes, alcohol, and drugs. Getting a complete smoking history is a critical part of the subjective assessment process. A good history helps me to understand what function or role smoking plays in the life of LaToya, and forms the basis for developing a solid plan to help her quit. I asked LaToya to tell me about your smoking: How did you start? How old were you? What functions or purpose does smoking play in your life? How much do you smoke? Has your smoking patterns changed recently? If so, can you tell me why? Tell me about your past quitting attempts: How many times have you tried to quit? What, and when was your longest quit...