Client’s Background and Health Status, Term Paper Example

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Term Paper

Patient’s Holistic Pattern Assessment (Subjective and Objective Summary for Client’s Background and Health Status)

Background of the Patient

The patient that has been observed for this case is a 48 year old male who has no immediate family and is living with himself. Although single, he is constantly engaging in stressful situations especially when he is at work. With at least 50 to 65 hours per week spent on work, his focus is mostly dedicated to his job. Having a history of having an appendectomy during his 20’s and several issues regarding kidney stones, the patient is also diagnosed to be a non-insulin dependent diabetic individual who constantly experiences hypertension.

The vitals of the patient is regarded to be specifically right for his age although it does have some irregularities especially in recognition with some of the functions of its systems due to particular health issues garnered from his lifestyle and health history pattern. Standing at 6 feet one inch tall, the client weights 275 pounds and has a BMI of 24.4. The normal blood pressure of the patient is normally at an average of 150/100 and his temperature commonly rests at 98.4 Celsius. His regular pulse rate is recorded at 85 per minute with a respiration rate of at least 20 breaths per minute.

At this point, it could be observed that the complexity of the patient’s health status indicates his need to constantly keep watch both on his food and his activities so as to make sure that his stability is at a balance. Living in a constantly stressful pattern of lifestyle, he is most often than not experiencing the symptoms of hypertension. This particular situation has been regarded to have come from the fact that the patient’s family has had a recorded pattern of being diagnosed to have experienced hypertension as well [from the client’s parents towards his grandparents]. These diagnoses have been regarded to have occurred alongside other health conditions that probably contributed to the existence of hypertension. Hence, besides the factor of work stress and lifestyle course, the patient’s case also draws down the fact that his genes specifically dictate the occurrence of the health irregularities that he is currently experiencing.

Heath Issues

Some of the body function irregularities that are present in the patient include unevenness in the abdominal area which causes a rift on the abdominal wall later on causing more pain that the patient tends to endure. Above all that are remarkably normal, it could be seen that the client’s slightly elevated blood pressure is the primary concern that must be given particular attention to. As of the moment, there are four particular main problems that the patient is in need of dealing with. These problems are noted as follows:

Bulge Disc

C: the client feels lower back pain around L-5 locations which radiates to the right side of the body

O: the lower back is recurring for the past 10 years with different levels of inference every year.

L: The pain flows from L-5 towards the right

D: The pain lasts for a couple of days once the pain begins.

S: the pain remains at the back location never going down to the legs with a characterization of growing from at least dull to sharp aches

P:  the pain is heightened with prolonged time of sitting down at work and lifting heavy weights in the gym

A: concentration is lost when the pain is felt; due to the need of extending the capacity of the patient to finish his job, he takes in advil to alleviate the pain.

Heartburn

C:  characterized by chest pains usually after completing a rigid activity such as his regular exercise which he completes at least within 30 minutes.

O: the occurrence of the ailment usually begins every after the completion of a rigid activity and ends with a responsive resting habit; however at work, such resting process cannot be completely comprehended with.

L: the pain specifically remains within the chest and is prolonged for quite several minutes

D: since the activities of the patient is regularly stressing at work and at some point is aggravated with gym exercises, the patient complains of having regular chest paints at least several times each week.

S: the worst chest pain that the patient experienced was when it was accompanied by loss of breath or difficulty of breathing making it harder for the patient to recover from the situation.

P: most likely, it is the rigid activities that worsen the situation and the coffee-intake practice that the patient embraces [which has been advised by his doctor to be better controlled]

A: takes OTC pepcid for heartburn and Advil for the pain of headaches that usually occur alongside the heartburns

Cough and Allergies

C: the cough that has been reported by the client already lasts for a week. It started as a simply cough and gradually progressed now causing him chest pains and the hardship to breathe. The chest pains have been described by the patient as sharp especially during the coughing phases.

O: the occurrence of the cough was assumed to have began during a stressful day that the client had to compel with and a gym exercise he usually use to release his stress, but at that time, he over exerted himself resulting to irregularities in his breathing system [later on developing to sharp coughs perhaps due to the tension build up and the existence of excessive perspiration and the climate from outside].

L: the primary target of the pain is on the client’s chest and larynx.

D: the duration of the cough already lasted for a week

S: the chest pains have been described to sharp especially during the coughing spells

P: the pain is worsened when lying down at night

A: the cough and the pain it results to is eased with the use of Claritin [medication] and the practice of sitting up straight during the day.

Foot Problem

C: client currently suffers from foot infection which usually causes him to itch and produce bad odor on his feet.

O: the athlete’s foot of the patient was a developing situation that specifically came from sweaty feet from excessive workouts in the gym and unhygienic practices

L: the feet of the patient is the specific concern for the situation

D: the progression of the system was developmental hence was not given attention by the patient at first until it actually became a nuisance to the daily activities he hopes to complete.

S: the disturbance that the situation causes the patient is uncanny as it does affect his workouts even his work procedures as he becomes irritably concerned about the matter.

P: Excessive workouts and lack of hygienic practices worsen the case

A: changing cleaning routines seem to help alleviate the problem but do not completely cease the occurrence of the irritation on the part of the patient.

Health Beliefs

The personal and religious conviction of the client towards health and the occurrence of illness helps well in the process by which he manages himself to become more aware of his conditions and deals with the difficulties with better approach. Knowing that his situation draws down from his genetic makeup, he considers the need to exercise daily in a regular basis as a strong source of his health’s stable condition. Hence, he considers this matter as an essential need to be followed. Although he does believe that God provides for his need of healing, he also considers himself as the primary reason for the occurrence of such healing and that he must be able to do something about the situation to actually be able to accept the healing that God is willingly able to give.

Treatments and Ethical Conditioning

As a regular patient who has a record on most of the healthcare facilities he visits, he expects that the healthcare providers who would attend to him would have better command on what they are supposed to do once he comes in for particular emergency situations or at least for some healthcare issues he might be dealing with during the time. Notably, his respect and trust towards healthcare givers makes it easier for him to follow their instructions especially on matters that he does not have control over such as infections that are occurring on wounds that he incurs due to his diabetic condition. He is highly cooperative to healthcare givers especially if he feels that they put their client-responsibilities first above all others.

Reflections and Remarks

Considering the client’s conditions, healthcare status, lifestyle, beliefs and personal assumption and expectations of healthcare providers attending to him, it could be analyzed that he would be easy to handle especially if his rights and expectations are given particular attention to. The patient seems to have great command of his lifestyle and is probably considering the fact that he has to stick to routines that he has set for himself to remain healthy. Giving him comments of appreciation for such would help in making the patient remain at ease towards the compassion that the healthcare providers have towards him. Making it easier for him to survive current healthcare issues is very much essential in a healthcare provider’s role in helping him cope up with his present condition and healthcare problems.

Extending consideration to the fact that the patient knows so much about his health case could help the healthcare providers to make assumptive claims when dealing with his needs through asking him thorough questions that could respond to explaining some complications that might be happening to his case. Nevertheless, it helps for a healthcare provider to look up his record thoroughly so as to make sure that the medications to be given him would fit his condition and give him the proper ease that he needs. Respecting his rights and recognizing his efforts to remain healthy would make it better for the healthcare provider to see the desire of the patient to remain healthy and thus be able to respond to that particular desire accordingly.

References

Swaminatha V. Mahadevan; Gus. M. Garmel (5 July 2005). An introduction to clinical emergency medicine. Cambridge University Press.

Weber, J., Kelley, J., & Sprengel, A. (2010). Lab manual to accompany health assessment in nursing (4th ed.). Philadelphia: Lippincott.

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