NUR 335 Practicum Assignment 5.1
NUR 335 Practicum Assignment 5.1
Denver College of Nursing
NUR 335 Practicum Assignment 5.1
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| Demographics | |
| Initials: ___L.A_____________
Age:___40________________ Sex: ___male________________ |
Primary Language Spoken: _Chinese______________
Cultural Background:__chinese__________________ ______________________________________ |
| General Health | |
| How would you rate your general health?
|
The patient reports to the clinic for an evaluation, he reports that he believes that he has a fair general health. NUR 335 Practicum Assignment 5.1 |
| Have you had a wellness checkup with a healthcare provider in the past year? | The patient states that for a long time now since the outbreak of the Covid 19, he had not had any meeting with his doctor physically he however states having virtual meetings on several occasions |
| Have you ever been told by a health care provider that you have a chronic disease such as hypertension, diabetes, heart disease, stroke, arthritis or kidney disease?
|
This patient states that he has a history of hypertension and pre-diabetes. L.A has been having this for the past five years but has been able to manage the conditions well. |
| In the past month, have you had pain on more than three days that impacted your ability to perform your normal daily activities?
If yes: · Where was the pain located? · What have you tried to relieve the pain?
|
The patient states that he has not had Pain or major changes in his daily activities that might lead to irregularities for the last three days. This is mostly because he has been able to manage these two conditions well. |
| How would you rate the quality of your sleep?
· How many hours do you regularly sleep in a night? · Do you ever wake up before you wanted to? · Do you have problems falling asleep? |
L.A states that he has been experiencing sleeping and wake up in the middle of the night. the patient states that he finds himself sleeping at an average of six hours per night and sometimes wake up in the middle of the night and find it difficult getting back to sleep. |
| Medications | |
| Are you currently taking medicine for any chronic condition?
· Do you know what the medication is used to treat? · Have you missed doses of your medication in the last week?
|
The patient is currently taking hypertension Acebutolol medications in order to address his irregular heart beat problem. L.A states that he is very keen and ensure that he take his medications as indicated by the doctor. He has never missed to take medications since he has set a reminder on his phone. |
| Women Only: | |
| Are you pregnant or planning on becoming pregnant in the next year? | N/A |
| A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
· If yes, when was your last mammogram?
|
N/A |
| A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
· If yes, when was your last Pap test?
|
N/A |
| Men Only: | |
| A PSA test is a test for cancer of the prostate. Have you ever had a PSA test?
· If yes, when was your last PSA test?
|
He states that he had his last PSA test the last time he visited his doctor three years ago. He had a free PSA reading of 0.12. He did not report pain and no any symptoms and thus he was assured that he had nothing to worry. |
| Lifestyle | |
| Do you now smoke cigarettes every day, some days or not at all?
· If you are currently smoking, have you tried to quit? · If yes, what methods have you used to quit smoking? o Were the methods successful? |
L.A states that in his entire life, he had never smoked. This was because he had witnessed firsthand information about the negative effects of cigarettes as his father died of lung cancer that was largely due to his smoking behavior. |
| For the questions below consider the past week in your answer: | |
| How many times did you take part in physical activity of at least 30 minutes during the past week?
· If yes, what type of physical activity? · If no, why? · Was the past week representative of your normal level of physical activity? |
For the past ten years, the patient states that he has developed a habit of taking early morning jogs and that he does this at least twice per week. he states that during the last week, he did his usual one hour morning walks on Friday, Saturday and Sunday. |
| How many hours a day in the past week do you think you spent on sedentary activities where you remained sitting for extended periods of time?
· What activities were you doing during these times? |
The patient states that in the last week, he would spend more than four hours watching movies on Netflix. He states that finds himself watching movies every time he is not doing anything and is just chilling at home. |
| To the best of your recollection, what food items have you eaten for breakfast in the past week? | The patient states that he does not have a very good appetite but he tries a lot eating a balanced diet. He recalls that in the past week, he included fruits, eggs, milk, bread and vegetables in his breakfast.
|
| To the best of your recollection, what food items have you eaten for lunch in the past week? | For his lunch during the last one week, he recalls largely taking bananas, sausages and crackers. He sometimes completely taking his lunch especially when the office schedule was very tight.
|
| To the best of your recollection, what food items have you eaten for dinner in the past week? | In the last one week, some of the food items that he took for dinner included mushroom, meat, beans, and sometimes non-fried Chinese food and soup. He however noted that he only took small portions as he largely has an issue with his appetite.
|
| What beverages do you routinely drink?
· How many times per week did you drink soda or pop? · How many glasses of water do you drink in a day? |
The patient states that he loves taking coffee and rarely does he take sodas. He states that he drinks approximately six to seven glasses of water every day. This however goes up to 12 during his exercises. |
| Do you eat snacks throughout the day?
· If yes, what snacks do you routinely eat? · What time in the day do you regularly eat snacks? |
The patient states that he does not routinely take snacks throughout the day. |
| How many times per week have you skipped meals? | The patient states that for the last one week, he skipped lunch twice. LA states that he sometimes skips his lunch due to his busy schedule in the office. |
| For the questions below consider the past 30 days in your answer: | |
| What is the largest number of alcoholic drinks you had on any occasion in the past 30 days? | The patient states that he does not take alcohol at all. |
| Have you used any drugs or other substances, other than those that are prescribed for medical reasons?
· If yes, what substance(s) did you take? · How many times have you used this substance in the past 30 days? |
LA has never taken any drugs apart from the ones prescribed by his doctor. He states that he does not know how most of these drugs look like and has avoided coming into contact with them at all costs. |
| In the past 30 days, how many times have you eaten a meal outside of the home; at a restaurant or other venue? | The patient states that he is not used to eating outside. He recalls only two occasions in the past 30 days when he had to eat outside. One was in a restaurant and the other one in his friend’s house. |
| For the question below, consider all lifestyle behaviors (combined) in your answer: | |
| Do you believe you lead a healthy lifestyle?
Please explain your answer?
|
LA believes that although he has not been able to completely live a healthy life, he believes that he has tried his best to make sure that his body is healthy and that he is able to manage the two conditions. |
| Mental Well-Being | |
| How often do you experience stress that exceeds your ability to cope?
· What strategies do you use to control stress?
|
The patient states that he sometimes feels much stressed especially because of his condition and the medications that he has to take all through. He manages his stress by listening to music, watching movies and doing some exercises. |
| How often do you get the emotional and social support you need?
· Who would you describe as your support system?
|
he believes that he gets the required support especially from his wife and his two kids who are always supporting him. |
| Over the last two weeks, how many days have you felt down, depressed or hopeless?
· If you have felt these feelings, what actions did you take to make yourself feel better?
|
The patient states that he has not felt down in the past two weeks. This is however not always the case as sometimes he is very down. |
| Access to Preventative Services | |
| Do you feel you have access to preventative health screenings and education?
· Do you have health insurance? · Have you ever skipped care (Prescriptions, therapy, specialist visits etc.) that was recommended to you because of concerns regarding the cost of the care? |
The patient states that he has access to preventative care, insurance and he does not skip appointments apart from the Covid Period where he was forced to talk with his doctor virtually. |
| Education | |
| Where do you normally receive health information? Examples could be the internet, health care provider, family or friends, etc.
|
The patient states that he looks for information online and in nursing journals. He also contacts his doctor when he feels that he cannot access the information that he needs on these platforms. This has really helped him to keep on tabs regarding what he has to do to keep fit. |
| What health topic(s) would you like to have more information on, if available?
|
He states that he would like to know more about Covid-19 and diabetes so that way he could be better informed about how to live healthier. |
| Other Assessment Information | |
|
|
I discovered several health-related issues throughout this evaluation. To start with, this patient is proficient in Chinese, which makes it difficult for me to comprehend this patient when he speaks English. Additionally, there are various times when this patient often misses meals (Othman et al., 2020). This patient has a higher than average risk of developing diabetes as a result of his poor diet as well as the long time that he spends watching movies. When I assessed this patient, he had to rephrase numerous words so that I could understand him well. Despite this, his accent still made it difficult for me to understand him. The patient also expressed concern that he would need an interpreter for his doctor’s appointment because his English isn’t as good as possible. He states that there are times that he has had a hard time with his doctor when he speaks to them, and so he has to write things down to make sure they grasp what he is saying.
Diabetes is the primary health issue I’m focusing on for this patient. Because this patient already had a pre-diabetic diagnosis. Because of his limited command of the English language, this patient is unable to comprehend the information being provided to him regarding his health. Diabetes is a concern for the patient, who expresses concern about learning about it. |
References
Othman, E. H., Shatnawi, F., Alrajabi, O., & Alshraideh, J. A. (2020). Reporting nursing interventions classification and nursing outcomes classification in nursing research: A systematic review. International Journal of Nursing Knowledge, 31(1), 19-36.
