Chronic Pain related to unknown etiology as evidenced by self-reports o

GNRS 578 Health Assessment Lab Week 10

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Health History Assignment – Part 2

Student Name

School of Nursing, Azusa Pacific University

GNRS 578, Health Assessment

Instructor’s Name

Date

2

Health History Assignment – Part 2

No sample. Please include an introduction that frames the purpose and application/uses of

a health history. For guidance, refer to the beginning of Jarvis, Chapter 4.

Problem Lists

This patient is an 80-year old Caucasian female. The actual problems for this patient are

bilateral leg edema, difficulty walking, obesity, hypertension, hyperglycemia, joint pain, back

pain, depression, and anxiety. The potential problems for this patient include risk for clots due to

immobility, risk for diabetes mellitus, risk for dehydration, risk for fall and risk for infection due

to incomplete immunizations.

Assessment and Analysis

Patient Perspective of Presenting Problem

The presenting problem of bilateral leg edema is not much of a concern for the patient.

Since that patient has experienced this before and the edema has resolved with diuretics, the

patient believes that the edema will resolve with the same treatment. The edema does not

contribute to her anxiety nor impact her life. The patient only describes the edema as

inconvenient when she needs to wear shoes to go to her doctor’s appointments. The patient is

lying down most of the day, so she does not notice the leg swelling or weight gain from the

swelling. She states that the cardiologist has told her she does not have a heart issue and she

believes her edema is caused by her immobility. She reports that she needs to move around more

to possibly prevent water accumulation in her legs and avoid gaining more weight. The patient is

more concerned about her overall additional weight gain from the swelling, aside from her

sedentary lifestyle and overeating. The patient does not have any spiritual concerns that need to

be addressed.

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Overview of Significant Concern Areas

The presenting symptom of edema of the bilateral lower extremities is the major concern

area for the patient with associated mild weight gain. Since the patient’s physician ruled out any

heart conditions, the patient believes her immobility is causing the issue and that she needs to

move around more. In one study that was conducted on individuals with gait disturbances and

without any venous abnormalities or systemic diseases, successful management of leg edema

was achieved through compression and physical therapy (Suehiro et al., 2014). With these

findings, it was assumed that leg edema was due to immobility that caused venous stasis

(Suehiro et al., 2014). Since the patient has difficulty walking herself, she should get help from

outside sources, such as physical therapists and compression therapy as suggested by evidence-

based research. With the patient lying down most of the day and usually only noticing her leg

edema when she must wear shoes, the patient must also pay more attention to the swelling

variations of her lower extremities. While the presenting problem of bilateral leg edema does not

cause the patient much suffering, it is important for the patient to monitor daily weight changes

to notice worsening symptoms. Daily weight monitoring allows for early detection of excess

fluid volume which can be balanced out with medication increases to prevent the need for

hospitalization (Wagner & Harden-Pierce, 2014, as cited in Ackley et al., 2020).

The patient also has difficulty walking, which causes her to walk extremely slowly. The

patient should start to walk more during the day, even if it means walking for a few minutes and

gradually progressing her way up the block. Even slow walking with turns can preserve muscle

mass and strength, facilitating further independence (Araki et al., 2017, as cited in Ackley et al.,

2020). Walking can also prevent venous stasis, which is a risk factor for clots (Huether &

McCance, 2020). As discussed above, the patient’s issue of having difficulty walking due to her

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rheumatoid arthritis and back pain should be intervened by health professionals if the patient

cannot motivate herself. Another study done to increase physical activity in patients suffering

from rheumatoid arthritis, revealed that posttreatment and 6-month follow up appointments

greatly increased the number of patients meeting the physical activity recommendations (Knittle

et al., 2015, as cited in Ackley et al., 2020). Through motivation and professional management,

the patient can be guided in a specific direction and be encouraged to self-monitor her times

spent on physical activity and more.

Having a body mass index (BMI) of 32.9 kg/m2 put the patient in the obese category.

The patient notes that she does not exercise and barely moves around due to the pain in her

joints. She is aware that her sedentary lifestyle and overeating is contributing to her weight gain.

A moderate weight loss approach is suggested for the geriatric population with a BMI over 30

(Ackley et al., 2020). It is recommended to limit simple carbohydrate intake and instead focus on

balanced high-quality nutrients, which includes high-quality meats of around 1.2 g per kg of

body weight (Blaze, 2016, as cited in Ackley et al., 2020). Since the patient’s daughter makes

most of the food and rice is usually eaten with Persian dishes she makes, the daughter needs to

limit including it with the meals. Based on the patient’s weight, she should be limiting high-

quality meats to around 98 grams as well.

Since the patient has rheumatoid arthritis, gait difficulty due to pain and a history of falls,

the patient is at risk for falls (Potter et al., 2021). The patient’s most recent fall was caused by

slipping on the rug by her bed. The patient should remove any throw rugs, declutter her home

and install adequate lighting in the house to help prevent falls (Potter et al., 2021).

Chronic depression and anxiety have been an issue with the patient for many years and

both concerns are part of the patient’s family history. The patient reports feeling depressed or

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anxious due to her inability to move about as she wishes. It has previously been found that 30 to

50% of chronic pain patients have depression as a comorbidity (Breivik et al., 2014, as cited in

Ackley et al., 2020). The patient states that she uses the television to distract herself most of the

time. If the patient begins to feel anxious or down, there are other techniques she can use to try to

feel better such as visualizing herself without anxiety and such, successful experiences of

situations or resolution of conflicts (Ackley et al., 2020). This strategy of guided imagery has

been used as a psycho-supportive intervention due to promoting comfort (Satija & Bhatnagar,

2017, as cited in Ackley et al., 2020).

The patient has a family history of colon cancer on her father’s side. New technology has

brought about the fecal immunochemical test (FIT) that detects blood from an ulcer or polyp in

the colon from an individual’s stool sample (Jarvis, 2020). With the patient having a family

history of colon cancer and having her last colonoscopy 3 years ago, the FIT test is a simple,

noninvasive tool that the patient can do annually to detect possible abnormalities of the colon

sooner. If the test is ever positive, the patient will then have to do a colonoscopy to confirm

colon cancer or determine the next steps (Jarvis, 2020).

Evaluation of Nutritional Data

The patient reports eating cheese as part of her breakfast meal every day. Since the

patient has a history of hypertension, she should become aware of foods that have high amounts

of salt in them, including dairy. It is recommended that people who have hypertension follow the

dietary approaches to stop hypertension (DASH) diet, which suggests reducing sodium intake to

less than 2300mg per day (Grodner et al., 2020). The patient also consumes rice regularly, which

is made with added salt by her daughter. One major way of reducing sodium intake is to avoid

adding salt when making rice (Grodner et al., 2020). Reducing salt intake can also help treat the

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patient’s presenting problem of bilateral leg edema (Huether & McCance, 2020). The daughter

can take pre-portioned meals instead of a large container of rice to help the patient lose calories

since she is considered obese and is not exercising. During breakfast, the patient usually has

bread as well. Since the patient is eating a similar breakfast daily, she should substitute her bread

for a whole-grain bread. This will help fulfill the suggesting seven to eight servings of grain

products, that increases intake of minerals and fibers (Grodner et al., 2020). Chocolate and ice

cream is eaten just about every day too, which can contribute to high amounts of sugar. Not only

does the patient have to reduce this intake to adhere to the recommended 5 servings a week of

the DASH diet (Grodner et al., 2020), the patient needs to decrease her sugar intake because of

her diagnosis of hyperglycemia and to reduce the risk of its progression to diabetes mellitus. In

addition to contributing to extra glucose and calories, the daily intake of ice cream is a source of

saturated fat and does not fulfill the recommended 3 servings of low fat or non-fat dairy products

(Grodner et al., 2020). The patient should instead turn to low fat or non-fat dairy products like

frozen yogurt to comply with the recommendations of reducing saturated fat and total fat or at

least buy a healthier version (Grodner et al., 2020).

Although the patient can apply many of these modifications, one of the patient’s strengths

is satisfying the recommended 4 to 5 servings of fruits per day (Grodner et al., 2020). Another

one of her strengths is eating fresh poultry, fish, and lean meats rather than fattier foods or cured

meat (Grodner et al., 2020). The patient does not really consume fatty foods. While the older

population is more at risk for Vitamin D deficiency (Grodner et al., 2020), the patient does take

supplements to prevent this, especially since she is not under the sun much. While it is currently

unlikely, it is possible for the patient to become deficient in Vitamin B12 later due to the general

decrease of intrinsic factor production in the older population, which helps with absorption

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(Grodner et al., 2020). The patient notes drinking about 4 cups of water a day, rather than the

recommended 8 glasses (Grodner et al., 2020). Due to the patient’s presenting problem of

bilateral leg edema, the amount of water the patient drinks should be discussed with her

physician to prevent further complications.

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Nursing Diagnosis

NANDA:

Excess fluid volume related to excessive sodium intake as evidenced by peripheral edema

and weight gain.

Patient

Goal/Outcome

Interventions Rationale for

Interventions

Evaluation of Each

Goal/Intervention

Patient will explain

at least two actions

that are needed to

treat or prevent

excess fluid volume

including dietary

restrictions and

medications as well

as maintain the

appropriate body

weight of 178

pounds within the

next 6 weeks.

1a) RN will assist

patient in switching

to a restricted-

sodium diet and

will teach patient

how to

appropriately take

diuretics prescribed

by the provider.

1b) RN will help

patient monitor

daily weight for

sudden increases

using the same

scale and type of

clothing at the same

time each day,

preferably before

breakfast.

1a) Restricting the

sodium in the diet

will favor the renal

excretion of excess

fluid (Rudge &

Kim, 2014 as cited

in Ackley et al.,

2020, p. 414).

…diuretics

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