NR 302 RUA Health Assessment SA, a 63-year-old Caucasian female residing alone in a rural area with strong family support.

Health History Assessment

The individual selected for this health assessment is SA, a 63-year-old Caucasian female residing alone in a rural area with strong family support. SA perceives health as a balanced state, involving regular exercise and a nutritious diet. She describes herself as between healthy and unhealthy due to some ongoing health issues. SA engages in physical activities about once a week and maintains a predominantly healthy diet, yet she is motivated to improve her overall well-being by enhancing her exercise routine.

SA’s medical history encompasses several chronic conditions, including degenerative disc disease, hypertension, hyperkinemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis. Her surgical history includes neck and back surgeries, gallbladder and cataract removal, and a hysterectomy. Her current medication regimen consists of Spiriva inhaler, Allegra, Valium, Zoloft, gabapentin, Lopressor, and Protonix. SA’s family history reveals that both parents had hypertension, potentially contributing to her own condition. Her mother had asthma, which could have influenced SA’s respiratory health, while her father, a cigarette smoker, was diagnosed with lung cancer, and her mother also suffered from anemia, requiring multiple blood transfusions.

Review of Systems

SA has minimal skin issues, limited to eczema, with normal nails and some greying hair. She reports no headaches, head injuries, or dizziness but does experience neck pain when turning her head to the right. No lymphatic issues are present. SA’s vision is slightly compromised due to cataracts, for which she wears glasses, and she underwent cataract surgery in June 2015. Her auditory health is good, with no ear infections or hearing issues. Although she has allergies to pollen and dust, SA experiences no significant sinus problems. Her mouth and throat health is generally good, without sore throat, lesions, or toothaches. While asthma and emphysema cause occasional shortness of breath, they do not hinder her ability to perform daily activities like cooking, cleaning, and self-care. Her only cardiovascular concern is high blood pressure, which she manages through medication and reduced salt intake.

Developmental Considerations

Having dealt with asthma since childhood, SA’s health condition has shaped her lifestyle significantly. Her respiratory limitations restricted her participation in sports and prolonged physical activities, impacting her social interactions and contributing to challenges with weight management. Throughout her life, SA has associated her struggles with weight control with her asthma, as the condition limited her physical activity options.

Cultural and Psychosocial Considerations

SA’s upbringing was marked by an interest in religion, specifically church attendance and Bible study, though her family did not share the same religious devotion. Her father’s discouraging remarks regarding her spiritual interests created a challenging environment, which hindered her connection with her faith community. Psychosocially, the loss of her husband nearly a year ago has heavily impacted SA’s social life. She finds it emotionally difficult to attend social events, as they remind her of activities once shared with her spouse. Despite this, her children visit regularly, with one visiting daily, and they maintain a weekly family night, which brings SA comfort and a sense of companionship.

Collaborative Resources and Reflect