Health History Interview- Using Gordon’s Functional Health Patterns

Health History Interview- Using Gordon’s Functional Health Patterns

Client Profile and Developmental History

The patient, a 38-year-old male, presents himself for a check-up with concerns following prolonged experiences of pain and discomfort in the chest. He reports feeling dizzy and sometimes having near-fainting episodes. He notes he flutters in the chest, feels lightheaded, and has fast racing and a slow heartbeat. The patient states that he has been married for seven years with a family of four, including a 3-year-old son and a 5-year-old daughter. He is physically overweight. The patient satisfactorily complies with the interview process. Based on his age, the patient is currently in the generativity versus stagnation stage in Erickson’s development stage. During this stage in life, the individual is more focused on starting and raising a family, meeting other family obligations, being productive in society, growing in their professional field, and having a sense of purpose in life (Nantais & Stack, 2020). Although the patient is meeting most of the stage’s expectations, the current heart health concerns are a risk to his ability to fulfill all of the expectations.

Health Assessment of Major Systems

As per the interview with the patient during the assessment of his major systems, he reported that he had no current history of respiratory problems. However, he reported that his maternal grandfather had a cystic fibrosis diagnosis and had a lung transplant. The patient reports that he does not engage in any lifestyle that may risk his “lung and breathing health,” like smoking. He does not report of any allergies related to the respiratory system and confirms that he does not smoke and has no allergies. Notably, his lungs are clear to auscultation. The patient reports irregular heartbeats. The assessment shows that his blood pressure is elevated. He does not report taking any medications for the condition. Further objective cardiovascular assessment will be required. Upon musculoskeletal interview assessment, the patient reports that he does not have a history of musculoskeletal issues. However, he reports he has been developing joint pain, especially at his knees and ankles, which he thinks is due to his increasing weight, and he also mentions that his father has arthritis. His joint movement is within the normal range of motion, and he has a normal gait.

Health Perception/Health Management Pattern

Based on the assessment interview, the patient rates his chest pain when it occurs at a 7 on a scale of 10. He notes that he has experienced weight changes in the last 5 years following his love for KFC chicken, fries, and soft drinks and a sedentary life working at the office. Despite the weight changes, he did not pay much attention to it. However, based on his noticeably overweight state and the current “bad” heart health, he feels if he does not “do something” now, things will get worse in the next 5 years. He does not report of any allergies or current medications except a few over-the-counter medications he takes from time to time to manage the pains. He notes that he does not know the actual names of the medications since he just asks for pain medications. He also reports that he has done nothing so far to manage his weight. He has no history of substance abuse and notes that he avoids alcohol as it is damaging to his health. The patient appears noticeably overweight but well-dressed and oriented. His O2 saturation is at 91%, which is lower than the normal 95% and 100%, which may be related to heart arrhythmias. Evidence purports that atrial fibrillation affects oxygen uptake and may cause lower oxygen concentrations in patients (Takano et al., 2019).

Nutritional Metabolic Pattern

The patient states that his diet and fluids are majorly composed of high-calorie, low-nutrient diets as he loves pizza, KFC chicken, and fries, as well as soft drinks. He reports he has noted significant weight gain in the last few years. He denies any nausea and vomiting. Assessment of skin, hair, and nails shows that all appear healthy with shiny nails and well-maintained hair, except that he has been developing stretch marks on the stomach, back, shoulders, and arms, which he attributes to his weight gain. He is 5ft 8 tall and weighs 194lbs. His BMI is at 29.7, which is on the higher end of overweight. He reports that he rarely eats vegetables as the taste is not “that appealing” to him. Unhealthy eating habits and lack of physical activity are leading factors to increased weight and obesity in both children and adults (Jia et al., 2021).

Elimination Pattern

Upon further interview, the patient reports regular bowel movements and has not noticed any changes or concerns. He reports that his last BM was this morning as per his morning routine, and the stool feels normal, though he is unsure of the color. He denies constipation, GI surgery, or the need for medication to facilitate BM. The patient reports no changes in his urinary habits, especially waking up in the morning and urinating, as well as the quality of his urine. He denies any problems with urinary function, including nocturia, incontinence, and dysuria. However, he reports that although his urination is smooth, it has become a bit more frequent in recent days. He, however, denies any bladder surgeries. Upon abdominal assessment, his stomach appears distended with stretch marks. Upon bowel auscultation, although faint due to the thick stomach wall, sounds were normal in all four quadrants.

Activity Exercise Pattern

The patient reports that his normal day between Monday and Friday involves working at a small office as an accountant working on a computer. He is mostly passive and has no regular exercise. He usually snacks at any point in his day and has his lunch and a 4 pm snack delivered to his office. His weekends are free, and he mostly stays at home. He reports that he is able to perform his ADLs independently and does not need any assistance. He reports that he used to and still plays video games for fun. He notes he has no exercise routine since he realized that his heartbeats were abnormal when exercising, and he tends to have problems breathing every time he engages in rigorous physical activity. Since he works as an accountant in a small office, he reports that sometimes he works overtime and sometimes hates his job but must do it for the sake of his family.

Sexuality Reproduction Pattern

The patient is a male of 38 years old. He reports that he has no concerns with prostate problems or any changes in his testicles. However, he is concerned with erectile dysfunction as he reports that since his weight has increased, he is becoming less sexually active and sometimes is too concerned to even have an erection. He notes that he only has sex with his wife and is less concerned with sex identity as he will forever be a man. He reports that he has never had any STDs and denies any history of sexual abuse. He also reports that he has never had concerns over his sexual health, so he never took regular check-ups seriously. He, therefore, has never had a reproductive health check-up, including a prostate check-up.

Sleep-Rest Pattern

The patient states that he perceives his sleep pattern to be healthy, as he sleeps mostly for 7 to 8 hours during the weekdays. He also states that he sleeps a bit more on weekends as he has nothing much to do except play with his children. On Sundays, he engages in some smaller activities in the local community, especially in managing the local churches and small groups’ finances. He reports that he does not need anything, including medication, to sleep. The patient reports that he has no sleep issues, including difficulty falling asleep or waking up; he just goes to bed and sleeps and wakes up as per his waking routine without needing an alarm. He describes his sleep as quality as he is able to sleep for 7 or more hours uninterrupted. He notes that he has not experienced any changes in his sleeping patterns during the weekdays. He states that his wife has recently started complaining about him snoring. He denies waking up feeling fatigued or napping during the day.

Cognitive-Pattern

The patient is alert verbally and physically. He is well-oriented to person, place, and time. He comprehends the subject of this assessment interview and responds clearly to questions. He is also able to recall information provided from the start of the interview and other events in his life. He denies any problems with his ability to make clear decisions. He has quite a good attention span and remained attentive throughout the interview. An MSE shows that his attention and concentration, memory, verbal and mathematical abilities, judgment, and reasoning are within the range. He denies any history of memory problems or the existence of cognitive issues in his family.

Role-Relationship Pattern

The patient states he is close with his family. His wife is supportive, and his children are always happy to see him. He says his brother and sister always conduct him and check up on him. His mother visits during the holidays. He is the family’s main breadwinner, although his wife has a small greengrocer family business in the local town center. His family, except his wife, have no idea of his heart issues. He notes that his wife pushed him to have his heart checked. His wife and brother have also commented on his increasing weight and advised him to have it checked. He notes that no one at work knows about his health status, and he does not mind. He says his wife is the most important person in his life. He also views his children and siblings as the very important people in his life. He is only involved in his church and avoids most social events. He notes he loves living an actual life. The patient shows his call logs with multiple calls from his wife, brother, and sister as proof of having caring relationship patterns.

Perception/Neurological Assessment

The patient denies any visual or hearing illusions or hallucinations. He also denies any problems with his perception of taste and smell. The sight and vision, hearing, tasting, and smell assessment, including the use of sounds with eyes closed, various smells, and tastes, showed that he had no difficulties with any of the senses. The patient says he does not need any assistive devices for hearing, smell, and tasting. However, he says he uses “special” glasses only when he is working for a long time on the computer to reduce and prevent the computer screen’s light from damaging his eyes. A neurological assessment, including the level of consciousness and cognition, speech, and memory tests, shows he is well-alert in all senses, well-oriented to person, time, and place, and has no speech and memory deficits.

Coping-Stress Tolerance Pattern

The patient does not identify any other stressful situation in his life except his current heart health concerns and work-related stress, which he refers to as normal. The current heart rate situation and the risk of developing heart disease have got him stressed. He is very concerned about his health-related costs and is worried about becoming a burden to his family. He has marketplace insurance that covers all conditions, including chronic ones like heart disease. He reports that he has not had any personal loss or has made any major life changes in the last year. He states that he majorly copes with stress by talking to his wife, spending time with his children, and talking to his brother and sister. He denies using any substances to relieve his stress.

Value Belief Pattern

The patient reports that his family is the most important thing to him. He hopes to one day have his own accounting and taxation consultant agency. His main sources of hope and strength are his children and family, and he believes in God. He is a Christian, and this is essential in his daily living. He does not have any special requests related to treatment or any health practices or restrictions important during hospitalization. He only wishes that in case he gets hospitalized, the medical team will notify his church members to come and visit him and pray for him.

Summary

During the time of the assessment, the patient was 36 years old and identified as a male. He reported having concerns over the irregular heartbeats he was experiencing. He has poor eating habits with a more sedentary lifestyle, and has grown overweight. His symptoms indicate a risk for heart arrhythmias. He is visibly concerned about his health, supportive family, and social relationships. He is willing to make major changes to reverse his condition. The major goals for maintaining a quality of life are to manage the developing heart disease, reduce his weight, and overcome his poor eating habits and sedentary lifestyle. It is recommended that he takes a diabetes test owing to the fact he is overweight and has reported experiencing an increased frequency of urination.

 References

Jia, P., Luo, M., Li, Y., Zheng, J. S., Xiao, Q., & Luo, J. (2021). Fast-food restaurant, unhealthy eating, and childhood obesity: A systematic review and meta-analysis. Obesity Reviews, 22(S1), e12944. https://doi.org/10.1111/OBR.12944

Nantais, C., & Stack, M. (2020). Generativity Versus Stagnation. Encyclopedia of Personality and Individual Differences, 1773–1775. https://doi.org/10.1007/978-3-319-24612-3_589

Takano, N., Amiya, E., Oguri, G., Nakayama, A., Taya, M., Nakajima, T., Morita, H., & Komuro, I. (2019). Influence of atrial fibrillation on oxygen uptake and exercise tolerance in cardiovascular patients; close association with heart rate response. International Journal of Cardiology. Heart & Vasculature, 22, 84. https://doi.org/10.1016/

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Each student nurse will work with a partner (“the patient”) to complete a health history interview using Gordon’s Functional Health Patterns to document a narrative overview of the patient’s health.

The “patient” will be free to use their own personal information or may answer the questions in the interview acting as someone else (the “patient” does not need to disclose if the information is real or is part of acting as a patient). Students will follow the Functional Health Pattern Rubric, along with text or online resources for Gordon’s Functional Health Patterns and Erikson’s stages of development, to complete the assignment.