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Health Assessment

Healthhistory refers to the compilation of current and past health data.When organizing for a patient’s care plan, the provider should haveadequate information on the patient’s health history. Knowledge ofpast and present health can enable the provider to have an adequateunderstanding of the patient before producing the requiredintervention. When attending to the patient, it was necessary for thepractitioner to acquaint himself with the medical history. This iswhy important information on the patient’s family medical history,perceptions of health, reasons for care, demography, culturalconsiderations, developmental considerations, review of systems, pastmedical history, and present illness(Benetos, Novella,Guerci, Blickle, Boivin, Cuny &amp Passadori, 2013).

Objective Data

When an assessment of thepatient’s health history was conducted, it was revealed that thepatient called WD was admitted to the hospital for diabetes mellitus,cerebrovascular diseases, and heart failure. WD is a 105-year-oldfemale who has complex medical conditions. Her old age has exposedher to multi-morbidity conditions that have been making her seekmedical intervention for a very long time. According to ErikErikson’s theory of psychosocial stages of human development, thepatient is in the integrity versus despair stage(Wellard, Rasmussen, Savage &amp Dunning, 2013).However, unlike many elderly persons, she is content because she hasled a fulfilling life.

After assessment of the healthrecords, the patient was diagnosed with Cerebral infraction,Essential (primary) Hypertension, Heart Failure, Gastroesophagealreflux disease without Esophagitis, Mixed Hyperlipidemia, CognitiveDeficits, Type 2 Diabetes Mellitus, Constipation, and Primarygeneralized (Osteo) Arthritis. This is why when examined the patienthad inefficient tissue perfusion and immobile. So, to address thesituation, the provider, amongst other interventions, ordered her tobe placed on oxygen 2L/min, respiratory treatments, occupationaltherapy, speech therapy, physical therapy, sanctioning, and woundcare, tracheotomy to monitor the glucose levels, falls, aspirations,renal perfusion, and many other challenges.

Needs Education

Basedon her medical history and the results of her examination, thepatient should get adequate information on how to manage herconditions. First, she should be educated on how to manage herdiabetic conditions. Besides, she should be sensitized on theimportance of seeking medical care and collaborating with herhealthcare providers. When this is properly done, the patient willmanage to overcome all the challenges (Benetos,Novella, Guerci, Blickle, Boivin, Cuny &amp Passadori, 2013).However, the education provided should be responsive to the patient’scultural, emotional, and psychological needs. This is the only wayshe can be empowered to manage her conditions.


WhenI got an opportunity to interview the patient, we had a fruitfuldiscussion. Despite the challenges in her communication, I got tolearn about her medical journey. She told me that she had experiencedserious medical challenges on many occasions. However, she explainedto me that her old age does not scare her at all. She is happy withthe kind of life she has lived because she has no regrets. At thesame time, she acknowledges that old age is challenging. This is whyshe does not fear death because she knows it will finally come(Benetos,Novella, Guerci, Blickle, Boivin, Cuny &amp Passadori, 2013).

From this interview, I realizedthat I can learn a lot of lessons from my patients. Initially, Ithought that the patient would use her old age as an excuse not totalk to me. Besides, I thought she would tell me that she is notcontented with her life. However, when I got a chance to interviewher, I learnt that people can live a meaningful and fulfilling life.Therefore, no one should give up during old age even if they face amyriad of challenges. The interview was okay because I faced limitedchallenges. At the same time, the patient provided me with all theinformation that I wanted.


Benetos,A., Novella, J. L., Guerci, B., Blickle, J. F., Boivin, J. M., Cuny,P., &amp Passadori, Y.

(2013). “Pragmatic diabetesmanagement in nursing homes: Individual care plan.” Journalof the American Medical Directors Association,14(11),791-800.

Wellard,S. J., Rasmussen, B., Savage, S., &amp Dunning, T. (2013).“Exploring staff diabetes

medication knowledge andpractices in regional residential care: triangulation study.”

Journal of clinical nursing,22(13-14),1933-1940.