The essay discusses the physical and mental health profile of the client Miss G for interview and completion of a Comprehensive Health History. She is a student & part time retail assistant lives in City Apartments, Wintec, Hanultan, New Zealand. She was born on 19 October 1997 and in a De Facto relationship. She underwent cheiloplasty, nasal repair, alveolar bone graft and fistula repair, tip rhinoplasty, toe repair, eardrum repair (tympanoplasty) and rhinoplasty. The essay also discusses the purpose of subjective data, the rationale for the health history, client's strength, and health risks, the importance of client education and health promotion and developmental considerations.
Brief description of client
The chosen client for the interview is Miss G who is 19 years old female. She is a student & part time retail assistant and a New Zealand European with English proficiency and knows the Spanish and Maori language. Her family members include her mother, father, oldest brother and younger sister. She underwent cheiloplasty, nasal repair, alveolar bone graft and fistula repair, tip rhinoplasty, toe repair, eardrum repair (tympanoplasty) and rhinoplasty. Her general health is good; however, has a mental health history of depression and chronic mood swings when her parents got divorced.
Purpose of gathering subjective data
Subjective data is an essential component of health assessment of a client that involves the collection of information through effective communication (Reyes & Rosso, 2012, p. 756). In this data, the patient provides information about the physical symptoms and how one feels about it. This information helps to know the degree of pain that the patient is going through like discomfort, itching, pain or any abnormal sensations (Stumblingbear-Riddle & Romans, 2012, p. 1). In the subjective data provided by Miss G provides information about her past abdominal pain, mental health status and allergies. The subjective data also comprises of the experiences like vomiting, coughing or muscular spasms (Forbes & Watt, 2015, p. 175). In such kind of data, health beliefs are also mentioned that provide information about their attitudes, beliefs and perceptions (Coulter, Locock, Ziebland, & Calabrese, 2014, p. 348).
Collection of subjective data also encompasses feelings, sensations, desires, beliefs, ideas, personal information, ideas and values. This is important to know about the past medical history for the correct diagnosis, plan nursing goals and develop interventions according to the subjective data provided by the patient (Crisp, Douglas, Rebeiro, & Waters, 2016, p. 245).
Rationale for each component of the health history
The rationale for obtaining past medical history is important as it contains pieces of information that help to know about the current and past health history of the client (Cole & Bird, 2013, p. 325). The diagnosis helps to provide information about the various aspects of mental and physical health conditions like depression, retardation, hypertension or other medical conditions (Jones, Jones, & Del Campo, 2013, p. 115). The known allergies also provide information about the allergies to food, medications or any bee sting and plan to avoid those the client is allergic to. Past family history, information up to three generations is important to know about the environment, lifestyle and genes (Thornton, 2013, p. 456). It gives us a clue of the medical conditions that are inherited in the family tree. The pattern of inheritance also provides information about the patterns of disorders and the risk for developing that particular condition. Personal strengths, health beliefs, social activities and stress management information is important as these factors also affect the quality of life and health outcomes (Hareven, 2013, p. 305).
Client’s strengths related to health and well-being
The client personal strength is that she is dedicated to her study and work. She is a hardworking girl, high family oriented, multitasking, pursue task, and love to take challenges. Her life values and personal beliefs are her strengths that help her to lead a happy and contended life. She values respect a lot and are always kind to others irrespective of the person. She respect elders, put them at first and believes that they are experienced people and one always keeps learning from them. As she is a hardworking girl, she believes that it is the key to success and very thankful to the Almighty. She believes that education is the foundation for a successful life and one should never take his or her life for granted. This assessment is necessary to avoid any kind of conflict with the client’s personal beliefs and increased participation of the patient in the care plan and decision-making process.
The client’s risks to health and well-being
As such, Miss G has no risk to her health and well-being as she maintains a healthy lifestyle with proper rest and weight and nutritional management. However, she had a past mental history of chronic mood swings and depression. This took place when her parents got divorced. This poses a risk to her health and well-being as it has a detrimental effect, as she is family oriented and respect elders. She is bonded with her family, and parents’ separation negatively affected her. Her birth mother has a migraine that might act as a risk factor for her that affects her physical and mental health status. In addition, her mother also suffers from depression, post-traumatic stress disorder migraine and hypotension. She is at risk as she might also develop any of these mental health disorders, as there are chances of inheritance. She had undergone seven surgeries that have deteriorated her quality of life and well-being. Her father suffers from high cholesterol that might also act as a risk factor, although she leads a healthy and active lifestyle. The family history of Miss G also suggests that depression, high diabetes and mental health problems run in the family that can be the biggest health risk factor for Miss G.
Health promotion/client education
Health promotion and client education is important for the patients to motivate and encourage them to seek good health that acts as a desirable state by adoption of healthy practices (S?rensen, et al., 2012, p. 80). Health promotion through the adoption of healthy lifestyles and advertising of healthy practices help them to avoid the unhealthy lifestyles and behavioural factors that might put one at risk. Client education is vital as it provides information on how to maintain good health. Client education is a type of educative strategy that has a preventative objective to help client adopt healthy behaviour and maintain a healthy lifestyle.
Education provided to the client by a healthcare professional is an important tool for the management of care plan, provide preventative measure and promote good health for a quality living (Schulz & Nakamoto, 2013, p. 5). Apart from health literacy, health promotion is necessary for the client to enable him or her to increase control over the health and improve it and exercising control over the determinants of health. In the given health, history of Miss G, the client education and health promotion is required in terms to empower her to lead a normal life after her past surgeries. Client education would help her to have an improved understanding of her medical conditions, manage the multiple aspects of her health and have self-advocacy to act independently and increase her compliance and motivation. When she would be educated about her medical condition, it would help her to respond well to her treatment and care plan with less complication. Educating Miss G would also help to enhance her safety and cope with her stress and anxiety related to her health condition.
Developmental considerations are important as every person has different capacity to understand, comprehend and integrate the concepts of loss and separation and physical finality (Ng, et al., 2012, p. 340). As Miss G is an adult, she can accept her physical conditions and the separation of her parents. However, she is a very family-oriented person and respect elders, so it was difficult for her to cope up with her parents’ divorce and separation. Due to this, she had depression and chronic mood swings as mentioned in her mental health history. This shows that for her developmental considerations, it is important to provide her emotional and psychosocial support so that she can cope up with the stress and pain of her parents’ separation. Counselling can also be provided to her as a part of the developmental consideration and promote self-advocacy.
From the above discussion, it can be concluded that she underwent a health screening consisting of STD and STI swab test as she reported abdominal bleeding. She was screened for ectopic pregnancy and ovarian cysts. She has an allergy from bees and mosquitoes that cause swelling in the infected areas, instant dizziness, acute burning and itchy pain at the infected area. The purpose of subjective data is to know about the past medical history for the correct diagnosis, plan nursing goals and develop interventions according to the subjective data provided by the patient. The health template is helpful in increasing her control over her health and improves her condition. In addition, it is important for the client education and health promotion to help her lead a normal life.
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