...Family Nursing Diagnosis and Assessment September 3, 2012 University of Phoenix Nursing 405 Ginger Witherington After spending time with my family and assessing their daily activities it is very apparent that they all need help coping and finding a solution to the growing problem within their home. By using the Friedman Family Assessment as a guideline to identify the structural framework of this particular family, nursing diagnosis and interventions can be drawn as a guide to help with the healing process of their family. According to Healthy People 2020, one particular goal is the “Reduce substance abuse to protect the health, safety, and quality of life for all, especially children”. (Healthy People, 2020). Alcohol and drug abuse is a pattern that is accompanied by failure to fulfill responsibilities such as work and family and can have harmful personal, physical and emotional consequences that lead to the downfall of family. The population that I believe most effected by substance abuse in the family is the children. When there is long term abuse, complications that arise are violence, domestic abuse and fatal accidents such as overdose or the results of drinking and driving. From the nursing standpoint there are several interventions and strategies that can be instrumental in helping a family in crisis. Giving necessary support, providing educational resources and counseling resources are just three small areas that are important for the nurse to provide...
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...Family Nursing Diagnosis Susan Kenney, RN NUR/405 June 9, 2014 Beth Edwards, MSN, FNP-BC Family assessment, roles and structure The family I have been working with consists of three sisters who live in a house owned by the eldest of the three, C.H. C.H. is a 64 year old Caucasian female who was born with cerebral palsy and mental retardation. She has never been able to walk, and her mentation never progressed past the age of an approximately 4 year old child. She lived at home with her parents and two sisters and one brother until the age of 11 when she was institutionalized in a facility notorious for the mistreatment and neglect of its residents. The facility has long since closed, and in 1991, C.H. was placed with our organization, Community Vision Inc. (CVI). Her parents were both deceased by that time, and her sister D.H.C. assumed legal guardianship, with sister N.W. helping with her needs. CVI is a non-profit organization that assists disabled individuals to live as independently as possible, and enables them to purchase and live in their own homes if possible. We provide caregivers and in collaboration with social services and interdisciplinary personnel facilitate the supported individual to live to their maximum potential. Each person has their own individual service plan with health, safety, and vocational goals, and staffing is provided as required to meet the individual’s needs. Assessment of C.H. and her living situation The home the sisters...
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...UNIVERSITY College of Nursing BASIC CONCEPTS PRACTICUM – NURS 3263 DATA COLLECTION TOOL Student’s Name Date April 5, 2011 Biographical data Client’s initials P.M. Unit/Room No. A735 Age 64 years old Gender F Ethnicity Black Religion Baptist Marital Status Widowed Occupation Unemployed Date of Admission March 31, 2011 Admitting Problem/Diagnosis Unstable Angina Chief Complaint (Why did the patient come to the hospital – in patient’s own words) “My chest was constantly hurting and I couldn’t figure out what was causing it and now my back is killing me.” Past Health History Asthma ________ Emphysema _______ Bronchitis ________ Pneumonia ________TB________ Angina ______ MI ______ Anemia ______ Hypertension _______ Rheumatic Fever _______ Pacemaker _______ Peripheral Vascular Disease _________ Blood Disorders _________ Stroke _________ Skin Disease ______ Bladder Infections _Kidney Disease ___________ Ulcers ________ DM _________ Dental Problems _________ Fractures _________Congenital Heart Defects Surgeries Family Health History Condition Family Members Condition Family Members Heart Disease Mom died of heart attack Tuberculosis Hypertension Asthma Stroke Mental Illness Diabetes Alcoholism Cancer Aunt died of mylethoma Kidney Disease Other Health Problems in Family: ___________...
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...Health History and Screening of an Adolescent or Young Adult Client Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include the relevant data for your client. Student Name: Date: Biographical Data Patient/Client Initials: C. M Phone No: Address: Birth Date: Age: 15 Sex: Female Birthplace: Marital Status: Single Race/Ethnic Origin: White Occupation: Student Employer: N/A Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) Income is adequate for life style, patient is a High School Student at the current time, and lives at home with parents, there is a concern regarding her health, regarding asthma, bronchitis at this time. Patient is unemployed, but is covered under parents insurance BCBS. Source and Reliability of Informant: Patient is a poor historian, but patients mother is present at the time and is a good historian for patient. Past Use of Health Care System and Health Seeking Behaviors: There is a previous use of Health Care System for hospitilation, mother states that the patient does not usually have any health seeking behaviors. Present Health or History of Present Illness: Patient during the past 3 days has developed a progressive cough with mild production of green phlegm, and nasal congestion, that has not been relieve with OTC medication...
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...Present Health or History of Present Illness: Constipation | Past Health History | General Health: (Patient’s own words)Patient states she is in overall good health. | Allergies: (include food and medication allergies) Strawberries | Reaction: Hives | Current Medications:None | Last Exam Date: 4/2015 | Immunizations: All immunizations are up to date. | Childhood Illnesses: None | Serious or Chronic Illnesses: None | Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) When she was 5 years old she had tubes placed in her ears due to recurrent ear infections. | Past Accidents or Injuries: None | Past Hospitalizations: None | Past Operations: Myringotomy | Family History(Specify which family...
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...especially when the patient views these changes to be insurmountable? Provide a nursing diagnosis with interventions and outcomes to assess the patient's behavior changes. First the nurse would have to determine the patient’s understanding of what and how changes can affect his recovery. The nurse could then develop a plan based on the patient’s knowledge and readiness. Once a teaching plan is developed, the nurse could then divide the plan into small steps that the patient can take and build upon in time so that the task does not overwhelm the patient. Like in the need to decrease the amount of salt in his food. Instead of telling him absolutely no salt, say instead of adding extra salts to your foods try a salt substitute like Ms. DASH and look for soup that have the heart healthy sign on them. Then further educate the patient on the effect of salt on his damaged heart and what it could mean if action is not taken. This would use the health belief model in that it has explained to the patient what health related action needs to be taken in order to avoid a negative health condition. Nursing diagnosis: Stress overload related to major lifestyle changes as evidenced by patient stating “I am just so overwhelmed with all this happening so fast, one day I’m healthy and the next day I have heart attack and find out I wasn’t as healthy as I thought”! (nurse nanda,2012) Interventions: Provide family support with educational documents on how to change diet. As set patient up for...
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...Family Health Assessment Valerie McNeil Grand Canyon University: NRS-429 November 24, 2013 Family Health Assessment As nurses it is essential to use appropriate tools to assess individuals, families, and communities. Throughout this paper the writer used The Gordon’s 11 Functional Health Patterns as a guide to assess a family. This family included a mother, a father, one son, four daughters, and two grandsons. The writer developed two to three open minded, family focused questions for each of the 11 functional health patterns. In this paper the writer summarizes the findings of each functional health patterns of the family, and identifies three wellness nursing diagnoses based on the family assessment. The family being interviewed has a well pattern of health perception and health management. None of the family members have been hospitalized for long periods of time. The family members do not use drugs, or tobacco. Two of the older kids do drink alcohol occasionally, but the rest of the family does not. The family does not have the best nutritional-metabolic patterns. The family does not use vitamins or supplements, as well as the daily intake of food does not have a well balance of fruits, vegetables, grains, dairy, and protein. Two of the family members have eczema, and multiple family members have dental problems such as cavities. Most family members do not have problems with bowel patterns or bladder control. The father of the family has colon cancer and his bowel pattern...
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...Biographical Data Comprehensive health assessment are done to evaluation an individual current, past, and potential medical health problems in order to effectively treat people. The person who I am performing health assessment is a 26 year old male, who recently was admitting to our local community hospital for severe abdominal pain. He is Hispanic who lives with his older sister. Have 2 small children who lives with their mother in a different residents. Family Past Medical History Patient’s past medical history are diabetes mellitus, hypertension, current smoker who smoke about 4-5 cigarettes a day. Patient was admitted for stomach pain, nausea and vomiting for the past 10 days. To start, the patient family history is his mother who is 49 years old, have diabetes mellitus, coronary artery disease, and hypertension. Next his father who is 53 years old, have history of hypertension, COPD, a current smoker and have asthma. His sister is 28 years old who also has asthma. System assessment Patient is alert and oriented to self, time, person and situations. Right and left pupils are round, size 3 and brisk. Mucus membrane is moist, minimal oral problem, no missing teeth. Skin is intact, warm, dry color is appropriate for ethnicity. Abdominal is soft and flat. Bowel sounds are active and present. There are slight tenderness, and no guarding. Appetite has been decrease due to pain, nausea and vomiting. The last bowel movement was 4 days ago prior to his admission. Urinate...
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...health screening and history. Students who do not work in an acute setting may "practice" these skills with a patient, community member, neighbor, friend, colleague, or loved one. Complete the "Health History and Screening of an Adolescent or Young Adult Client" worksheet. Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. Complete the assignment as outlined on the worksheet, including: 1. Biographical Data 2. Past Health History 3. Family History: Obstetrics History (if applicable) and Well Young Adult Behavioral Health History Screening 4. Review of Systems 5. Include all components of the health history 6. Use correct acronyms or abbreviations when indicated 7. Develop three Nursing Diagnoses for this client based on the health history and screening. Include: one actual nursing diagnosis, one wellness nursing diagnosis, one "Risk For" nursing diagnosis, and your rationale for the choice of each nursing diagnosis for this client. While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the...
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...Community Health Nursing Reflection NUR/405 August 7, 2012 Community Health Nursing Reflection According to Phyllis Meadows (2009), “Community health nurses are valued for their adaptability and willingness to provide care in many settings, including community health clinics, churches, homeless shelters, and schools,” (p. 19). Community health nurses aim to improve health outcomes and improve the infrastructure used to monitor and manage disease within the community. Healthy People 2020 has established benchmarks and monitored progress over time to improve health outcomes. Each community has unique needs and the role of the community health nurse is to work with and provide comprehensive care to patients within the community. This reflection addresses the role of the community health nurse with the participating family and their community in Spring Mills, Pennsylvania. Community health nurses working in the Spring Mills, PA are faced with numerous challenges in this small rural community. Construction and manufacturing account for 42% of the industry of Spring Mills. With these professions comes increased risk of work related injuries and illnesses. Educational services account for only 3% of the industry, wholesale and retail trade account for 10%, accommodation and food services 15%, and 30% account for a combination of professional, scientific, and technical services. Community health nurses play a role in ensuring safety in the workplace by creating and implementing...
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...Nursing Process Paper Nursing involves following certain procedures, regulations, and guidelines. Nurses follow the nursing process, which is a reasoned and organized method of planning in order to provide care using critical thinking skills. The nursing process is a set of steps in which are designed to provide excellent and professional care (American Nurses Association, 2017). Critical thinking skills are used to identify, treat, and avoid health issues while also promoting wellness. Within the nursing process there are five phases, which may include; assessment, diagnosis, planning, implementation, and evaluation (American Nurses Association, 2017). The first phase of the nursing process is assessment. Nurses use assessment for analyzing...
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...perform a case study of a healthy child. Developmental considerations and data analysis were used to formulate and prioritize three nursing diagnoses. A complete health history interview was performed on a 17-year-old female. A genogram was developed to help determine potential genetic predispositions. J.K.M. is a 17-year-old female born on May 9, 1994. The first part of the interview was done with her mother present. Her mother was then asked to leave to continue to interview. As a child she had normal childhood illnesses without complications. All of her immunizations are up to date. She had no injuries or illnesses requiring hospitalization. She started menstruating at the age of 12. She is still menstruating and has normal 3-5 day periods while on Nuva-ring and her cycle is every 28 days. She has started dating and has been sexually active off and on since the age of 16. Both her parents and one sister are alive. There is a history of alcoholism and depression on both sides of her parent’s family. Her parents are divorced. She lives with her mother and sister and states they all get along very well except for the occasional disagreement. She does not see or communicate with her father. She denies any drug or alcohol use. She states that she is usually happy but she is concerned about the depression and alcoholism that runs in her family. She has no suicidal ideation and has never been physically or sexually abused by anyone. She participates in the cheerleading...
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...Family Health Assessment Introduction A comprehensive family assessment provides a foundation to promote family health (Edelman & Mandle, 2011). Marjorie Gordon developed 11 functional health patterns. They provide a systematic approach for nurses to use during the assessment process. By using this assessment tool the nurse can collect data about functional health patterns. By identifying certain behaviors through this assessment process the nurse can better tailor an appropriate nursing diagnosis, interventions and plan of care. This family health assessment paper has been organized and prepared in the following fashion. First, the questionnaire has been created which includes the 11 functional health patterns. A diagnosis has been presented in “Diagnosis” section, according to questions generated, using course textbook (Weber & Kelley, 2010) and guidelines for specific learning outcomes and conduct of therapeutic conversations by undergraduates from Holtslander & Smith (2013). The proposed list of questions and its format has also been quantitatively evaluated and compared to other documented experiences of family diagnosis using Gordon's 11 functional health patterns (Nettle et al., 1993; Kriegler & Harton, 1992) and their questionnaires used (Nettle et al., 1993). Finally, a wellness family nursing diagnosis has been inferred, based on materials from Weber & Weber (2010). Discussion The interviewed family consists of three currently active members –...
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...Health History and Screening of an Adolescent or Young Adult Client Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include the relevant data for your client. Student Name: ss | Date: 12/11/14 | Biographical Data | Patient/Client Initials: mkl | Phone No: 442-898-7721 | Address: | Birth Date: | Age: 22 | Sex: F | Birthplace: | Marital Status: S | Race/Ethnic Origin: Caucasian | Occupation: Student | Employer: N/A | Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)Unemployed, BC/BS of California | Source and Reliability of Informant:Self | Past Use of Health Care System and Health Seeking Behaviors: Patient has had regular annual exams growing up. Patient is current on all vaccinations/immunizations. Patine sees PMD annualy. Resently she saw Endocrinologyst to r/o hormonal disbalance due to exess facial hair grow and acne problem. | Present Health or History of Present Illness:Good. Hx of HAV, abnormal liver panel test | Past Health History | General Health: (Patient’s own words)“I am in a good health. I do have problem with acne and I am using Proactive to treat it. I am still trying to loose weigh and working out 3-4 times a week. | Allergies: (include food and medication allergies) NKDA | Reaction:N/A | Current Medications:Multivitamins, Ca, Supplements | ...
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...Illness:tonsillitis | Past Health History | General Health: (Patient’s own words)Over all good health with frequent sore throats | Allergies: (include food and medication allergies) NKDA | Reaction: | Current Medications:Oral birth controlAmoxicillin BID x 7 days r/t tonsillitis | Last Exam Date:03/21/16 | Immunizations:Up to date, had at 15 | Childhood Illnesses: tonsillitis | Serious or Chronic Illnesses:Had RSV at age 13 months, reoccurring tonsillitis | Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) | Past Accidents or Injuries:none | Past Hospitalizations:Hospitalized age 13 months for 3 days related to RSV | Past Operations:none | Family History(Specify which family member is affected.) | Alcoholism (ETOH use/abuse): paternal great uncles | Allergies: mother PCN |...
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