NUR 315 Health History and Family Genetic History Write-Up
Name: Date:
Instructor’s Name:
Health History (175 points):
The focus of this assignment is on communicating details within the written client record. When taking a health and family history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do not need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.”
| BIOGRAPHICAL DATA (10 pts) | |
| Date: | |
| Initials: | |
| Age: | |
| Date of birth: | |
| Birthplace: | |
| Gender: | |
| Marital status: | |
| Race: | |
| Religion: | |
| Occupation: | |
| Health insurance: | |
| Source of information: | |
| Reliability of source of information: | |
| PRESENT HEALTH HISTORY/ILLNESS (15 pts) | |
| Reason for seeking care: | Annual health checks to include blood pressure and lab work. No major complaints. Occasional headaches due to sinuses, lack of sleep, or stress relieved by Ibuprofen. |
| Health patterns: | Client has annual pap smear performed. Client also receives flu vaccine every year and is up to date on all vaccines required by place of work. She works 36-48 hours a week. She hopefully has 6-8 hours of sleep a night. She has recently (about 30 days ago) started to eat a heart healthy diet and tries to exercise at least 3 times a week. Client has dental exam every 6 months and a vision exam every 2 years. |
| Health goals: | To lose 20 pounds so she can feel better about herself and participate in more activities with her son. |
| HEALTH BELIEFS AND PRACTICES (15 pts) | |
| Beliefs and practices: | Client believes in seeking a healthcare professional for preventive visits (such as her child’s well-baby visits and annual pap smear with her ob/gyn). She will try home remedies for things such as a cold or sore throat; however, if symptoms are not relieved by these after 2-3 days, client will seek a healthcare professional. |
| Factors influencing healthcare decisions: | 1st Factor: Family and heritage influence. Client is part Irish and her family (mostly her mother) believes in home remedies.
2nd Factor: Availability of information. Client is a Registered Nurse, so she has a lot of sources of information available to her. |
| Related traits, habits or acts: | Client strongly believes in taking preventative measures. Client has annual pap smear and physical performed and has already made appointment to start having a mammogram next year, since she is now 35. Client does not drink, smoke, or use recreational drugs. She has started to live a healthy lifestyle by eating right and exercising regularly. |
| MEDICATIONS (15 pts) | |
| Prescription medications: | Include prescription order and reason for taking the medication |
| Over-the-counter medications: | One A Day Women’s multivitamin: 1 tab PO daily (has been taking for at least 2 years)
|
| Herbals: | None |
| PAST HISTORY (15 pts) | |
| Childhood diseases: | Chickenpox |
| Immunizations: | Up to date and includes Hepatitis B, MMR, flu, tetanus, D Tap, and annual PPD. Does not remember other vaccines but knows that she is up to date on those required by the hospital she works at.
|
| Allergies: | Food:
Drugs: Environment: |
| Blood transfusions: | None |
| Major illnesses: | None |
| Injuries: | Sprained right ankle about 3-4 times when younger. |
| Hospitalizations: | Only hospitalized for the birth of her child (see below) |
| Labor and deliveries: | Vaginal full term birth – December 11, 2007 |
| Surgeries: | None |
| Use of alcohol: | |
| Use of tobacco: | No. Client’s husband does smoke but not in the house. |
| Use of illicit drugs: | History of Marijuana use in late teens/early twenties; however, does not use now. |
| EMOTIONAL HISTORY (15 pts) | |
| Mental, emotional or psychiatric problems: | None; however, because her mother is bipolar, she fears she will become bipolar or develop other psychiatric problems. |
| FAMILY HISTORY (15 pts) | |
| Father: | |
| Mother: | Mother is 62 and states that “she is crazy” and is only aware of her being Bipolar. |
| Siblings: | None |
| Grandparents: | Two grandparents are still alive and she believes they have hypertension and heart disease. Other two grandparents died when she was young and does not know their cause of death. |
| PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts) | |
| Occupational history: | Hostess and waitress when younger, golf course beverage cart girl while in nursing school, and now a Registered Nurse. |
| Educational level: | |
| Financial background: | Does not want to disclose |
| ROLES AND RELATIONSHIPS (15 pts) | |
| Significant others: | Husband and son. |
| Support systems: | Husband, son, parents, friends, coworkers, and neighbors. |
| ETHNICITY AND CULTURE (10 pts) | |
| Ethnicity and culture: | Patient is Caucasian. She is half Irish but considers herself completely Americanized. |
| Physical and social characteristics that influence healthcare decisions: | Because of her occupation and her husband’s occupation (he is an EMT), she is influenced greatly by her husband, coworkers, and the healthcare system. |
| SPIRITUALITY (5 pts) | |
| Religious and spiritual needs: | She is Methodist; however, does not consider herself very religious. She believes in God, but does not go to church on a regular basis. She does admit to saying a prayer before dinner and before she goes to bed. |
| SELF-CONCEPT (5 pts) | |
| View of self-worth: | She believes she is a good person; however, thinks she will feel even better about herself once she loses a few pounds. She loves being a nurse, wife, and mother. She worries all the time about her son and wants to be able to provide him with a great childhood. |
| Future plans: | Her ultimate goals include being able to “jog, not run” a half marathon, and take a nice family vacation. |
| REVIEW OF SYSTEMS (20 pts) | |
| Skin, hair, nails: | Skin: Client reports tanning regularly on days off outside in the summer time and in tanning bed during the winter months. She reports very dry hands (believes it is from hand sanitizer and soap at work). No lesions, rashes, discoloration, or deformities noted. Patient showers everyday and shaves every other day.
Hair: Hairstyle is kept short and dyes hair with the changing of seasons (about 4 times a year). Washes hair every other day. Nails: Nails kept short. Client reports she use to bite nails when she was younger but has since stopped. Also reports that nails are thin, but they appear healthy. |
| Head, neck, related lymphatics: | Occasional h/a relieved by Ibuprofen. No swelling noted to lymph nodes. No abnormalities found with neck. Patient states occasionally she will wake up with a stiff neck if she “sleeps wrong.” |
| Eyes: | Patient alternates between wearing contacts and glasses. She uses them to see long distance. She reported having 2 styes this year and has since bought all new hypoallergenic eye makeup and uses an eye makeup remover versus just soap and hasn’t had a problem since. She has an eye exam every 2 years and is due for another eye exam this coming year in June. |
| Ears, nose, mouth, and throat: | Ears: Denies any hearing problems and stated last hearing exam she remembers was in middle or high school.
Nose: Client reports having occasional nose bleeds that she has had since she was a child. She usually has nose bleeds when she notices the air is very dry. Mouth: Mouth is pink and moist. Client reports having no problems and that she has a dental exam every 6 months. Brushes twice a day. Throat: Patient reports having viral tonsillitis a month ago, but reports no abnormalities at this time. She also has a history of having strep throat twice. |
| Respiratory: | Denies any respiratory problems. States she has seasonal allergies. No history of tobacco use. Her husband smokes, but does not smoke in the house around her and her son. PPD screening performed annually – last one was negative and next one is due in December. |
| Breasts and axillae: | Client reports having no family history of breast cancer. She performs self breast exam every month and has one done by a physician every year when she also has her annual pap smear. No lumps, discoloration, abnormalities, or drainage reported. |
| Cardiovascular: | Patient gets cholesterol checked every year as well as her blood pressure. Both are excellent and she does not take medication for either. She also states that she occasionally feels like her “heart is skipping a beat” and saw a doctor for this when she was 20 years old. She doesn’t remember the diagnosis; however, remembered that it was a common problem among a lot of people, she did not have to take medication, and if it started to bother her or get worse to notify her doctor. She did notice that when she reduced her caffeine intake, the symptoms decreased. |
| Peripheral vascular: | Her blood pressure is fine, normally running 100/60. She states that she does have spider veins and varicose veins. Her mother also has varicose veins. The client states her left leg is worse than her right leg and that her legs only feel sore after working a 12 hour shift and being on her feet for a long time. She states she should wear TED hose, but chooses not to because they are uncomfortable. |
| Abdomen: | Denies any problems. States she used to have 1 bowel movement a day, but since cholecystectomy she has about 2 bowel movements a day. |
| Urinary: | Denies any problems. States that the B50 vitamin turns her urine a bright yellow, but that just reminds her to drink more water. No history of a UTI. |
| Reproductive: | Uses condoms for birth control and states that birth control pills “made me moody and gain weight.” Onset of menses was age 13. Has a regular period every 28-30 days lasting 4-6 days.
Para 1 Gravida 1 Abortus 0 Reports having a great relationship with her husband. No history of any STDs. |
| Musculoskeletal: | Denies any problems. States she needs to exercise more including strength training. |
| Neurologic: | Denies any problems. All extremities equal and strong. No problems with gait. Pupils equal and reactive. No history of any head injuries. |
| Category | Points
Possible |
Points Earned | Comments |
| Biographical Data | 10 | ||
| Present Health Status | 15 | ||
| Health Beliefs and Practices | 15 | ||
| Medications | 15 | ||
| Past History | 15 | ||
| Emotional History | 15 | ||
| Family History | 15 | ||
| Psychosocial/ Occupational History | 15 | ||
| Roles and Relationships | 15 | ||
| Ethnicity and Culture | 10 | ||
| Spirituality | 5 | ||
| Self-Concept | 5 | ||
| Review of Systems | 20 | ||
| Clarity of writing | 5 | ||
| Total | 175 pts | Pts earned = | |
Family Genetic History (100 points):
Develop a family genetic history that includes, at a minimum, three generations of your chosen adult’s family including grandparents, parents, and the adult’s generation. If the adult has any children, include them as the fourth generation. This assignment is to reveal the potential impact of the family’s health on the adult participant. You do not need to identify anyone who is not biologically related to the adult except for a spouse/significant other.
Write brief descriptions for each person. Each description should include the following information: first name, birthdate, death date, occupation, education, primary language, and health summary including any medical diagnoses.
| Family Member | Description |
| Paternal grandfather
First and last initials: |
CF |
| Birthdate: | Does not know |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | My client was not able to provide any information on her paternal grandfather other than the name he was called. |
| Paternal grandmother
First and last initials: |
|
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Father
First and last initials: |
|
| Birthdate: | 1926 |
| Death date: | 1977 |
| Occupation: | Entrepreneur/ Business Owner |
| Education: | 9th grade |
| Primary language: | English |
| Health summary: | |
| Father’s siblings (write a brief summary of any significant health issues) | |
| Maternal grandfather
First and last initials: |
|
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Maternal grandmother
First and last initials: |
|
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Mother
First and last initials: |
|
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Mother’s siblings (write a brief summary of any significant health issues) | |
| Adult Participant
First and last initials: |
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| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Adult participant’s siblings (write a brief summary of any significant health issues) | |
| Adult participant’s spouse/significant other
First and last initials: |
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| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Adult participant’s children (write a summary for each child, up to four children)
Child #1 first and last initials: |
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| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Child #2 first and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Child #3 first and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
|
Child #4 first and last initials: |
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| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: |
Evaluation of Family Genetic History (25 points)
Evaluate the impact of the family’s genetic history on your adult participant’s health. For example, if the adult participant’s mother and both sisters have diabetes, hypertension, or cancer, what might that mean for the adult participant’s future health?
A minimum of one reference, in addition to the Health Assessment textbook, is required in this section.
My client health history interview revealed very important health information about herself, her parents, and grandparents. In evaluating her family genetic history, I observed that hypertension can be traced back to her maternal grandmother and genetically linked diabetes to her mother. My client was diagnosed with hypertension was approximately 10 years ago and is predisposed to diabetes. While gathering information and teaching my client about hypertension and diabetes, my client admitted that she knows hypertension and diabetes has been in her family and can be passed down for generations. She understood that being genetically linked increases her chance of having the disease. My client also understood that even though her parents and grandparents had the disease it does not means that she will inherit it. She understands that proper lifestyle management lowers the risk of getting the disease.
Health Promotion and Planning for Future Wellness (35 points)
Plan changes based on the evaluation of the adult participant’s family’s health history that will promote an optimal level of wellness both now and in the future. Include what information you would provide to the adult participant regarding the results of the family genetic history.
A minimum of one reference, in addition to the Health Assessment textbook, is required in this section.
Based on her health history of hypertension I would plan blood pressure monitoring often as possible. If client is not able to have blood pressure (BP) taken at home, I would provide information to her about joining a local clinic and to visit a walk-in clinic available at local stores where her blood pressure can be checked often and for free. I would review her BP medication and teach her about taking it at the correct time and the proper dose to ensure been effective. Teach her on proper diet-sodium intake, exercise, and stress management. I would encourage community involvement.
| Category | Points
Possible |
Points Earned | Comments |
| Family Genetic History | 35 | ||
| Evaluation of Family Genetic History | 25 | ||
| Planning for Future Wellness | 35 | ||
| Scholarly Writing | 5 | ||
| Total | 100 | Total Pts earned = | |
| Final Score |
References
