Mrs. R.K.B, a female African American aged 25, visited the hospital at Sugarland for her yearly well-woman visit on September 21st, 2020. A happily married woman who decided to go back to school as a full-time student. She is a mother of two children, a male, and a female.
Past Medical History
She stated, and her medical record shows she had completed her tetanus, hepatitis, chickenpox, and MMR earlier as a child. She had no records of surgeries or any hospitalization history. The patient has never had a blood transfusion. Mrs. R.K.B has been diagnosed with strep throat in the past. Health Assessment
She is currently on prescribed medication like Ibuprofen 400mg PRN for pains. She is also on Calcium Acetate 667mg once daily for bone formation. She also takes vitamin C 500mg once a day to boost her immune system.
Mrs. R.K.B’s perception of her health condition is good as she feels she is healthy and good. Compared to the regular African Americans who struggle with high blood pressure, diabetes, and high cholesterol due to their sedentary lifestyle. Also, most African America the same age as Mrs. R.K.B do not take the time to visit the hospital because of a lack of insurance, or they feel they are healthy so, they do not need to visit the hospital. The patient has an allergic reaction to chloroquine, she stated it irritates her skin, and she swells around her eyes. Health Assessment
Mrs. R.K.B engages in vigorous exercise 4 times a week for 30 mins, and she tries to keep fit to be able to care for her family. Her last well-woman checkup was okay, which the nurse educator encouraged her to continue performing this checkup to prevent and review her reproductive health from time to time (Jarvis & Eckhardt, 2020). The patient currently is a nursing student so, she is aware of the implication of an unhealthy diet, and her salt intake is medium because she is knowledgeable of what a high intake of sodium can do to people mostly, African Americans. So, at this time of the visit, the patient has no illness. Health Assessment
Family Medical History
Her mother was diagnosed with high blood pressure at the age of 38, which motives her to try to live a healthy lifestyle to avoid high blood pressure. Her father has been diagnosed with a cataract of the eyes, which he is yet to perform surgery to remove the cataract, and her siblings have no significant health problems. Her mental health states she is stressed, and she stated schoolwork and trying to take care of her immediate family’s day-to-day activities was putting a lot of stress on her because she has two children.
Reason for Care
Mrs. R.K.B stated, she started her menstrual cycle at the age of 13, which is an ideal age. Her last menstruation was on September 19th, 2020. She states her period is every 24 days, and she had never had a rectal examination. The reason for her visit was for a well-woman checkup. I asked her if she would want a Pap smear done today, and she wanted to know what a Pap smear was? I explained, “it is a procedure to test for cervical cancer in women” (Pap smear – Mayo Clinic, 2019). And she accepted the Pap smear screening since her main aim for her visit was for a good woman checkup. Mrs. R.K.B was taking her health as her optimum priority. Health Assessment
Due to her cultural belief, she stated she does not take alcoholic beverages, and at some period of the year, due to her religious beliefs, she fast. She explained she was a catholic, and during Lent, she avoids eating meat on Ash Wednesday and all the Fridays of Lent, and I documented that information in the system.
Review of Systems
When I went through the system, it stated she had been diagnosed with strep throat in the past. It was treated with some antibiotics, after which she was better. She has never had strep throat after the first incident. Health Assessment
During the assessment, the patient weight, height, and size were appropriate for her age. Going through her records on the system, Mrs. R.K.B started her first menstrual cycle was at the age of 13 years, which is within the right age of development.
Mrs. R.K.B, a mother of 2 children, talked about how much she loved spending time with her family. She talked about how her husband and the children supported her decision by going back to school.
HEENT (Head, Eyes, Ears, Nose, and Throat)
Before I got all the necessary information from Mrs. R.K.B, I started my assessment by first introducing myself to the patient. I verified with the patient if she was aware of what brought her to the hospital, which she was alert and oriented to the place and situation. Inspecting her face and it is symmetry with facial structures, her head is normocephalic without any lesions or infections noted. Patient two eyes are symmetrically placed, there are no infections to the eyebrows, eyelids, or eyelashes, there are no discharge, redness, or drainage noted. The patient has two ears, and they are both symmetrically placed looking at the patient ear. There is no redness, drainage, or discharge looking behind the ear. The patient nose is symmetric to other facial features, there are no wounds rash, or lesions noted. When I checked with the light, there is no foreign body, no inflammation or deformity noted. When inspecting the patient’s throat with a tongue blade, the uvula rises and falls at the midline. Health Assessment
When I inspected the neck for symmetry, I ensured Mrs. R.K.B’s neck was in the midline. I assessed her neck range of motion, palpated the lymph nodes, and I used a gentle circular motion to palpate the lymph nodes in front of the ear and, within the neck, I also palpated the thyroid gland for any abnormal findings, and everything was okay.
When inspecting Mrs. R.K.B, she is not using any accessory muscles. When I auscultated her anterior and posterior lung, it was clear to auscultation bilaterally. She has no scoliosis, Kyphosis, Lordosis, or no crackle sounds. The A/P diameter is less than transverse. Health Assessment
When I placed the bell side to listen to her carotid artery, the carotid pulses one at a time was 2+ and no bruits noted, no jugular vein distension. Right Aortic intercostal space and the left intercostal space pulmonic S2 is greater than S1, Erb’s point S1 was greater than S2, the Tricuspid and Mitral were S1 greater than S2 which was within the normal range.
I began Mrs. R.K.B’s neurological assessment by assessing her level of consciousness. I assessed if she was alert, awake, and aware of the environment. She was oriented to person, time, situation, and place. Her facial expression, speech, and general mood and affect were appropriate to the situation. I assessed her appearance, posture, dressing, and grooming and it was appropriate. Health Assessment
The contour is flat, and the abdomen is symmetrical. She has an even skin color, and it is appropriate for the patient’s race. (Epigastric, Umbilical, and Suprapubic Areas) No bruits were auscultated to the epigastric, umbilical, and suprapubic areas. Her bowel sounds are normoactive in all four quadrants.
When assessing Mrs. R.K.B’s musculoskeletal system, I began with the inspection. I inspected the corresponding joints, structure, and function of each joint to determine if a full range of motion is present. I palpated the joint and skin to note temperature, musculoskeletal or muscular deformation, and it was okay. I assessed her range of movement by asking her to do an active range of motion like flexion, extension, abduction, adduction, and pronation, which she was able to perform. Health Assessment
Peripheral Vascular System
In this part of the assessment, I inspected and palpated her arms. I noted the color of her skin and nail beds, the temperature, texture, and turgor of the skin, and assessed for any lesions and edema. I assessed the patient for a capillary refill, and it was less than two seconds, I inspected and palpated her legs, and there was no swelling or lesions noted.
Going through her family health history, and as an African American, Mrs. R.K.B has a great chance of developing hypertension later in life. Her mother was diagnosed with high blood pressure at the age of 45 years. One health educational need for Mrs. R.K.B is to always monitor her blood pressure and to avoid smoking cigarettes or secondhand smoking. It states, “hypertension is the leading cause of death and disability-adjusted life-years worldwide. In the United States, hypertension accounts for more cardiovascular disease (CVD) deaths than any other modifiable risk factor which are second only to cigarette smoking as a preventable cause of death for any reason” (Carey & Whelton, 2018) Health Assessment
Also check: Medical Health History