The following is a health history overview assessment of a 56 year of patient names Walter Jordan. The overview considers the objective and subjective information regarding the patient. It includes finding the interrelationship between these two constructs with an insight on the psychological, physical, cultural and spiritual values of the patient. The examination is done as a mode of assessment on the health standards of the patient to explain the different client behaviours showcased while utilizing prior knowledge and theories of health.
Demographic Data
It is concerned with the socio-economic information required within the health standard. The health assessment involves Walter Jordan, who is a 56-year-old patient. He resides in a simple suburban area called Minnesota with his family. The family constitutes his wife and three kids. He is competent and works within the suburb as a plumber. The nature of the job is not as dangerous as he can run processes without feeling a high risk to his life. The center of his work enables him to differentiate between the primary and secondary lifestyle.
Reason For Seeking Care
Care is critical to any patient, regardless of the nature of the illness. Walter has an annual checkup at the health facility where the intense diagnosis is made to the patient (Doyle & McCutcheon, 2020). The checkup is attributed to his diagnosis of kidney cancer and the removal of his right kidney. The magnitude of this illness demands a great sense of care to normalize or mitigate the side effects of the disease. According to the assessment, Walter demonstrated a high level of fatigue, especially after engaging in small work processes. Also, there were different spots of blood from the urine. From these symptoms, Walter needed to undergo frequent checkups as a viable preventive measure for this illness. The medical practitioner involved with his case recommended that he takes initiatives to see his urologist yearly to avoid possible complications. Seeking care is essential as it ensures that collaborative measures are put in place to ensure that the entire processual. Care is asked to create an avenue for the interdependence of variables.
Present Illness
At the moment, Walter elucidates a peculiar illness related to anxiety and depression. The assessment depicts the significant effects of the disease on the daily operations he undergoes. The cancer diagnosis is a significant cause of issues relating to depression and anxiety. After the loss of his mother, this state has become worse as he is unable to control the after-effects of the ordeal. He is worried that things may start to go wrong even after kidney surgery is over. He is under the opinion that the illness might not end, and the operation would be a waste. As a result, this is a primary causative agent for depression, stress and anxiety. The present illness of the patient demonstrates a diverse requirement for specific needs. These needs are directed to address the feelings and emotional demands of the patient. The aim is to provide efficient education services that enlighten on the possible signs and symptoms of anxiety and depression.
Perception Of Health
Walter has different thinking as compared to that of the practitioners about the health standards. According to Walter, being free from any illness is the only way someone is considered as healthy (Doyle & McCutcheon, 2020). The analogy he puts across is that people only remain healthy when they exercise regularly and being in a position to take a balanced diet. Through this, he understands that on the basis that he does not use daily, he is not healthy. His understanding is complete that he cannot dispute the different reasons he experiences illness and excruciating pain. About his age, he is currently undergoing an excellent level of pain in the muscles and the knee. The perception he has at the moment is not general enough to enable him to be motivated to exercise a healthy living standard. The lack of motivation can be helped through the cooking behaviour advocated for by his wife.
Past Medical History
The past medical history of a patient is essential in ensuring that the present assessment has a stable baseline. It gives the history of how the victim may have suffered within the years. In this context, Walter was diagnosed by cancer of the kidney in 2018. As a result, he was obliged to undergo surgery to remove his right kidney (Adeloye & Balogun, 2019). The expert suggested this mode of treatment because cancer had not yet spread to the rest of the body organs. At the moment, Walter is free from disease. In this case, the expert recommends that he takes a CT scan every six months to enable effective monitoring to ensure that the illness is under control. These modalities are viable in creating a valuable preventive measure. Walter is currently experiencing an increased level of depression and anxiety. The assessment illustrates that he has experienced this problem for a very long time now. To mitigate this illness, he has to take medication every night before he sleeps. It includes taking antidepressants and sleeping pills. However, the problem is that he cannot remember the names of the types of medication prescribed to him.
Family Medical History
The medical history of the family is essential as it gives an overview of the different symptoms existed and an idea of the genetic composition of the patient. It brings out a deeper understanding of the various ways in which the family have fallen victims to specific illness in the past. Research shows that family medical history can affect the present health condition within the area. Walter comes from an extended family of ten members. Out of these members, only two of them have an anxiety disorder. His sister suffered the most to the point that she was moved to a nursing home. The severity of this disease is greatly seen within the family members. The sister was diagnosed to suffer from osteoporosis, a medical illness that comes about from depression and anxiety.
Another family member was diagnosed with type II diabetes and is required to use insulin regularly. Walter is, therefore, advanced to perform actions that prevent him from gaining excessive weight. When this occurs, he will be at the risk of having type II diabetes. His family history also indicates how his father died of an illness that causes outpouching of the part of the stomach. It goes through the thoracic region of the stomach. It was dangerous because having this developed the inability of a person to eat well. It was challenging to engage in medication-taking due to his weak nature. Walter should, therefore, try to monitor his health due to the doctor’s recommendations to prevent different risks and complications.
Review Of Systems
An analysis of the existing systems indicateWalter’sesent state of Walter’s illness. According to him, his health may be right but requires to be improved effectively. The primary concern in watching his diet to control the weight gained periodically. The treatment plan indicated by the practitioner enumerates the demand for excessive weight loss by the beginning of removing moles from the system (Adeloye & Balogun, 2019). His skin’s nature makes him look for alternative ways of reducing the effects of the illness. To prevent issues relating to sunburn, he is mandated to apply ointment as a mechanism for sunburn cream. Walter states within the assessment that he wears glasses daily. The system indicates that Walter does not contain any ear damage. According to him, he is an overall guy and does not have different allergic symptoms. In relation, he gives the opinion that loud music does not seemingly affect his ability to hear. Walter does not have any mouth or tooth pains. In this case, there is no bleeding of the gums, which is a good sign. Based on the different ideas stipulated, there is no cultural segmentation and affiliation. He is opinionated that medication is not mandatory, especially when one gets sick. Through this, there is no chance of having depression or anxiety. There is no sign of distress, even when Walter engages in tedious work. Yet, still, he experiences different deformities within the muscles (Adeloye & Balogun, 2019). Walter regards the frequent consumption of medication as an act of misusing the drug. He does not experience any sort of complications and pain around the neck. Despite not being persistent in medicine, he agrees on the importance of taking a CT scan.
Also, it means that there is no swelling in different organs. When he engages in rigorous activities, he starts to get tired quickly, even after performing a small amount of work. Also, he has a significant passion for food. When it comes to eating, he agrees that nothing should be in a position to deter an individual’s appetite. Knowing the history of diseases within the family is essential. There are no cases of abdominal disease within his family. Even with the increased eating habits, he specifies that his bowel movements are healthy and have not yet been affected. Walter says that despite there being blood, there is no discomfort during this process. It includes a tremendous lack of pain, lesions and sore pain around the perennial area. In this case, he does not engage in any sterile technique. Additionally, he demonstrates that he has a significant symptom of depression and anxiety. The depression is caused by different things which affect the behavioural mechanism. According to him, there is definitely no history of lung diseases. About his kidney transplant, which has been developed. In his opinion, a CT scan is essential in motoring the progress of the treatment plan. To achieve this successfully, he is mandated to go for a six-month check-up to ensure consistency in treatment. Walter goes ahead to analogies that indicate his enormous pain in the knee.
Rationale For The Study
The reason for conducting the research is to conduct an assessment of the healthcare condition of the patient. It considers the past and present medical statistics and determines how well it affects the treatment plan endorsed to the patient.
Developmental Considerations
Erickson’sbased on Erickson’s theory, looks into the general nature and stagnation in the development stage (Tidy & Cox, 2017). According to Walter, the development state requires a consistent and reliable forum for growth. Walter has a stable plumbing job, which is successful, and it makes him extremely happy. According to him, his marriage is a complete success as he has been married for many years. Walter is satisfied with his family is tallying out and how he has successfully succeeded in running the family. In his opinion, he claims that he would not wish to change anything about his life and the things going around him.
Cultural Consideration
Culture is an essential entity in any healthcare assessment process. Walter has lived in the United States for a long time (Tidy & Cox, 2017). It has enabled him to be enculturated to the cultural values depicted by the norms and demands of society. Within this country, English is the primary language being spoken in this case. He needed to become aware of all the rules and regulations. He is proficient in reading and writing this. His affiliation with the American culture is seen on the baseline that he has not yet left the borders. The religious construct has made him become a catholic in dominion. Though he does not attend church regularly, it does not mean that he is a Christian. Cultural considerations illustrate that Walter does not have any cultural issues that a healthcare expert needs to perform their processes.
Psychological Consideration
Depression and anxiety are major illnesses that affect the mental order of individuals. The diagnosis for Walter forms a big step and change in his life. According to him, work can be stressful, especially when there are numerous clients (Tidy & Cox, 2017). As a psychological measure, he tends to relive his pain by watching television and movies. Walter is a huge fan of sports, which forms the baseline for his stress being relived. The utilization of different practicing techniques is essential in guiding this mechanism. Doing this makes him be less anxious by reducing the stress existing.
Collaborative Resources
Collaborative resources are the different strategies that involve people working together to fulfil a specific task. It is important as they provide a sense of togetherness within a treatment process. Walter joined a support group for people with the same predicament. It included people who had a significant problem with getting over a loss or were struggling to mitigate, control or curb a particular issue. He always went to these support groups once in a month to help him talk about anything. It is essential in assisting stressful problems to exist. The availability of many healthcare facilities, according to Walter, is enormous. Getting back to the working routine is the main recommendation for Walter. It includes performing different intensity workout plans that ensure that team management is well initiated. Through this, he is able to get his work-life in general. Since his wife does typically the cooking, it means that she is rWalter’sle in watching Walter’s diet. The nearness of these facilities is important since he is not allowed to walk for longer distances. It is attributed to the immense pain on his knee and the recent surgery for kidney removal.
Physical Exam
The assessment is utilized as an exam that illustrates the different conditions that the patient goes through. With regard to this construct, Walter noted that he had never experience any sense of allergies. It is attributed to the factual nature that his skin was warm, dry and was even in terms of skin tone. As a result, it made his skin be free from lesions, rashes and bruising. In relation, his hair is also free from lesion and dandruff infestation. The hygiene nature of Walter is on another level. His nails are short, smoothed and curved (Nichol, 2017). The magnitude of the assessment demands a high utilization of ideas and processes to find out the symptoms and the best way tWalters’sl. The top of Walters’s ear is clearly aligned to the top of the eyes. Skin breakdown has also affected the back side of the ear. In this case, there is no closer septum noted. The sclera of the patient is pink in color and effectively aligned. The ears and the outer part of the eyes does not have swelling, tenderness and drainage.
Walter illustrates that he values cleaning his body including small organs such as the nose, eyes and ears. In this case, there is no thyroid enlargement procedures. There was lack of swelling on differWalter’ss of the body. Walter’s chest ratio was 2:1 representing a cumulative number who have no self-esteem (Nichol, 2017). Through this, there is no chance of having depression or anxiety. There is definitely no sign of distress even when Walter engages in tedious work. Even still he experiences different deformities within the muscles. When he erects, there is no sign malfunction. His abdomen is symmetric to a great level. From his kidney removal strategy, there are different scars and marks imminent on the sides of the stomach. Bowel sounds are also heard in a hyperactive manner. According to Walter, the renal and aorta arteries constitute different underpinnings that do not demonstrate the abdomen’s mass and light palpitation. With diverse capabilities and work ethics, Walter has become a highly formalized individual. Since he is smooth and steady, he has a strange motion revolving around his neck. Through this, his speech is clear and compelling, thus easily associated with creating meaning among people within the society. The assessments illustrate that all his cranial nerves are intact, defined for a particular age. Besides, his sensory perception is very high. The pulse rate is also standard.
Needs Assessment
In any construct, knowing the needs of a patient. It considers the different strategies that can be endorsed to make the entire process a success. Understanding the needs of individuals is essential in defining ways of quickly and effectively meeting with the needs of the patient. Walter requires some training and education on the best eating habits and techniques for maintaining a healthy lifestyle. The dietary proportion indicates that he eats out a lot (Nichol, 2017). It constitutes high regard for unhealthy food. Education is essential in this case as it entails transmitting information on the different existing modalities of healthy living. It is necessary to know how best to curb and mitigate existing health problems. For Walter, these are possible avenues for eradicating depression or stress. Needs assessment helps to understand the different requirements that patients want. It helps in effective decision-making strategies.
Psychological and physical interrelationships
There is a significant interdependence on how the mind and the physical body works. The case illustrated indicates the illness of depression and anxiety emanating from psychological issues. When Walter performs heavy work from a physical state, he starts to developmental distortions whiindividual’ss harm. An individual’s personality affects their strength in handling issues. It determines their rate of perseverance about forming viable relationships within a society.
Reflection
About the health assessment, a clear understanding is derived between the interaction of the interviewee and me. It gives a definite opinion on how life is structured about the different health issues occurring. In my opinion, conducting the assessment was crucial in getting sufficient information for this construct. I regarded the interview as a success. Doing this history of the health was easy since the entire scope of study had”already been tackled (“History-Taking a”d Physical Examination,” 2017). The importance of the assessment is attributed to the realization of its importance to healthcare development. During the interview, I found it necessary to use different medical terminologies for consistency. Instead, I opted to use the terms that the interviewee could understand effectively. It was essential to get a clear response with no ambiguity. I had to initiate strategies to form groupings about the different changes that occur within the global center. These were important for ensuring that they share their opinions. Within the structure existed a high degree of barriers and obstacles (Nichol, 2017). To overcome them, I decided to integrate the needs of the patient to the questions. It included making a structuralized concept that aligns the items to away the interviewees can understand. By doing this, I prevented the existence of ambiguity in information generation. In the caser, the respondent did not realize, I made it open that they could ask any question for better understanding.
The interview experienced no anticipated challenges. These are crucial in destroying some issues. In this context, I was well prepared to counter all the possible difficulties that existed. When drafting the questions, I was able to seek opinions from different people. These are inclusive of medical practitioners and social experts. Being prepared meant that I could answer any question confidently and effectively without fail. I conducted a high level of research to find out the possible synergy where this technology can thrive (Nichol, 2017). Getting more information from the respondents required that a good relationship be formed. It means building a brand of trust between the patient and me. Also, I researched on matters relating to cancer of the kidney. The aim is to understand the ideological concerns based on this notion. Instead of knowing the general nature of the problem, I drafted follow up questions to know the details of the interview. The whole process operates within three designated propellants. These ensure that information relating to surgery is well elucidated. In my own opinion, the success of the interview was dependent on my “organization strategy (“History-Taking a”d Physical Examination,” 2017). Doing this prevents the loosing of information and the quality of data collected. There was no ambiguity in any questions or responses five when I started to arrange processes and facts and, as such, practical understanding.