Routine Assessment of a Client (Coursework Sample)

Routine Assessment of a Client
Student’s Name
Institutional Affiliation
BIOGRAPHICAL DATA
Date: 02/21/2015
Initials: R.T
Age: 56
Date of birth: 1959
Birthplace: Texas. I came here after my retirement at the age of 52.
Gender: Male
Marital status: married
Race: African American
Religion: Christian
Occupation: Retired factory worker,
Health insurance: Public aid
Source of information: Client, and wife, D.S. Client is alert x3. Able to answer all the question appropriately. Memory is intact.
Reliability of source of information: The primary caregiver is his wife who was a nurse and is reliable for the present health issues. She is in charge of administering all his medications and making arrangements for his doctor’s appointment.
PRESENT HEALTH HISTORY/ILLNESS
Reason for seeking care: I have been experiencing persistent coughing and wheezing sound. Sometimes I also have shortness of breath and pain in the chest.
Health patterns: I never had any health issues in my childhood nor in my school career. I was always active in my younger years in different sports and activities. My diet is rather simple and normal, composed of three meals a day. My wife and daughters try to maintain a healthy and balanced diet for me always.
Health goals: I want to be more independent so I can take care of myself. This time I will be very careful and take a good care of my health and will enjoy my life with my great grandchildren.
HEALTH BELIEFS AND PRACTICES
Beliefs and practices: I believe in medication but only when required and when advised so by a qualified physician. The medication part of my life is however mainly managed by my wife and children, with the guidance of my doctor.
Factors influencing healthcare decisions: I rely mostly on the advice and guidance of my doctor who instructs my children and wife on the kind of medications I should be on, and the health practices.
Related traits, habits or acts: None in particular
MEDICATIONS
Prescription medications: 1. Furosemide –40 mg 1 tab PO daily. To remove excess fluid from body.
2. Omega 3 Polyunsaturated Fatty acid – 1,000mg 1 cap PO daily. Preventing and managing heart disease.
3. Carvedilol – 25 mg 1 tab PO daily. For high blood pressure
Over-the-counter medications: Tylenol 325mg PO prn q 6hrs. 2 tabs for fever.
Herbals: none
PAST HISTORY
Childhood diseases: Chicken pox
Immunizations: Flu vaccine 2012 and pneumonia vaccine 2006
Allergies: none
Blood transfusions: Never had one
Major illnesses: I am diagnosed with high blood pressure
Injuries: None
Hospitalizations: I have never been hospitalized before
Labor and Deliveries: Not applicable
Surgeries: None
Use of alcohol: In my early 20s I indulged alcohol drinking for a very short period.
Use of tobacco: I never smoked in my life.
Use of illicit drugs: Never used.
EMOTIONAL HISTORY
Mental, emotional or psychiatric problems: Due to my current condition, I am now mostly dependent on the help and assistance of my family, my wife particularly. Our children, however, are always there for us whenever we need them.
FAMILY HISTORY
Father: My father was a woodcutter from Texas and he had no history of any illnesses, but he did get injured many times while he was working in the woods. He was however not much of a hospital enthusiast. He died from a car accident at the age of 76.
Mother: My mother died at the age of 82 from lung cancer.
Siblings: I was an only child
Grandparents: No knowledge of them.
PSYCHOSOCIAL/ OCCUPATIONAL HISTORY
Occupational history: I worked in a leather factory, in Massachusetts D.C for 25 years. I retired at the age of 52 years old.
Educational level: I went up to the high school level.
Financial background: We were a middle-class family. My wife was always a housewife. All our grains and vegetables used to come from our farm.
ROLES AND RELATIONSHIPS
Significant others: I still life with my wife who we have been married for more 30 years. Most of our friends are passed away.
Support systems: I live with my wife who assists me in most things. Our children too help. SPIRITUALITY
Religious and spiritual needs: I consider myself of the Christian faith. I, however, do not take part in most of the Christian activities
REVIEW OF SYSTEMS
Skin, hair, nails: Skin:...