Integrated Theory and Knowledge Development in Nursing, Questionnaire Example

Biographical Data

The client is a 13 year old female born in Staten Island, New York. She is Roman Catholic and the oldest child of three. She currently attends school and reports that she has never smoked cigarettes or consumed alcohol. Her mother is worried that she is not getting adequate nutrition and consumes too much junk food.

Past Health History

The client has no record of experiencing any major health abnormalities in the past. When she was 12 years old, she was mistakenly hospitalized for a case of mononucleosis, as the health care team had believed that her red blood cell count was abnormally low. When the client was two years old, she broke a bone in her right foot, but cannot remember which one. When the client was eight years old, she sprained her right ankle. Recently, the client has been coughing chronically and developing rashes on her hands. She has been tired more than usual, but believes this symptom is residual from the mononucleosis.

Family History

No fertility issues have been experienced in the family. The client’s mother began her menstrual cycle at age 14. The client’s maternal grandfather has severe depression and the client’s paternal grandmother has diabetes type 2, obesity, and respiratory dysfunction. The client’s mother and father both have sleep apnea and have normal BMI. Both the client’s maternal grandmother and aunt have experienced breast cancer and survived. The client’s two siblings are asthmatic.

Review of Symptoms

The client reports that the coughing and rashes begun at the same time that she was becoming extremely fatigued. After recovering from the mononucleosis, she claims that the coughing and rashes persisted. She has not taken any medication for these additional symptoms. The patient was asked if there have been any changes to the products that she has used recently, and the client claims that there is not. However, she believes that she has developed a case of hives that were similar when she used both her lavender scented deodorant and lavender scented lip balm. When the client applied the deodorant, hives appeared primarily in the torso region, while the lip balm resulted in lip inflammation in addition to inflammation on the extreme regions of the body. The client reports that when she stopped using these products, the hives would go away but the rashes would remain. She has since travelled to the emergency room because she believed she was having an allergic reaction that included slight breathing difficulty. She was not admitted to the hospital, but provided with an injection of Prednisone and asked to seek medical attention if the symptoms were to return.

Wellness Diagnosis

Since the client is at a young age, it is important for her to begin a diet that will help her grow through adulthood. Since she has been sick recently, this would include the elimination of junk foods and focus on a more well-rounded diet. Furthermore, it is recommended that the client exercises in order to prevent future sickness. While the client has not experienced any major health problems in the past, it is recommended that she undertake preventative care. Since the client is young, this will help counteract many potential health events that can occur in the future. Obesity prevention is important, as her grandmother has had many health issues related to her weight. Furthermore, since the client’s maternal grandmother and aunt had experienced breast cancer, the client is likely to be genetically predisposed. Thus, it is recommended that she remains in optimal health.

Diagnosis 1

From the client’s description of her symptoms, it is clear that she has asthma. Her siblings are both asthmatic, and the client has reported coughing and difficulty breathing. Furthermore, this asthma appears to be triggered by allergic reactions. In this case, we are able to determine that one of the causes appears to be lavender based products, although it is likely that other allergens exist for the client. It is recommended that the client use over the counter antihistamine medications in order to fight the allergy symptoms. In extreme cases in which breathing is hindered, emergency medical help should be sought. Furthermore, it is essential for the patient to visit an allergist for allergy testing. She will then be able to avoid these allergens and reduce risk for related sickness. Lastly, she should be provided with an emergency inhaler, to use only when asthma symptoms occur.

Diagnosis 2

The client appears to have a weakened immune system as a consequence of the mononucleosis. Since she didn’t have asthma and severe allergic reactions before this event, it was either causal or associated. Therefore, it is plausible that the client has a dormant version of the Epstein Barr Virus. It is therefore essential for the client to keep her symptoms controlled, as this is a chronic disorder. It is possible that the client will grow out of the related symptoms, but since this is uncertain, the focus must be on prevention and control.

References

Chin, P. L. (2008). Integrated theory and knowledge development in nursing (7th ed.). St. Louis, MO: Mosby.

DeWit, Susan (2009). Fundamental Concepts And Skills for Nursing. Missouri: Saunders Elsevier.

Radcliffe, M. (2000). Doctors and nurses: new game, same result. British Medical Journal, 320 (1085): 1085