donna t health evaluation paper composition

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Well being Assessment

Genogram, Gestational Diabetes, Ice Cream, Overall wellness

Excerpt coming from Essay:



The purpose of this genogram is to carry out the health assessment in the client overall wellness. The name of the client is Donna. M, a lady patient, old 49. The person is a registered nurse, however , her father was not a more living, and had been diagnosed with diabetes mellitus type 2 when he was 60 years and older prior to he passed away. Fig one particular reveals the genogram in the patient.

Fig 1: Donna’s Genogram

Her mother remains alive and has been clinically determined to have high cholesterol. Moreover, the patient has a living two friends, two sisters, a boy, and two daughters. Her son has been diagnosed with ATTENTION DEFICIT-HYPERACTIVITY DISORDER during her childhood and her little girl has been diagnosed with brain tumor and depression when the lady was a great adolescence.

The maternal grandpa was no more living and had kidney disease when he was 60 years of age. The maternal grandmother got died and been diagnosed with Alzhe/Dementia when ever she was 60 years and older. Furthermore, the familiar grandfather had the unfamiliar disease when he was 60 years and above before this individual died. Nevertheless , the familiar grandmother was diagnosed with colon cancer when ever she was between 60 and fifty nine years of age and was been diagnosed with type 2 diabetes. She was above 6 decades of age just before she passed away. The patient has a living mother’s uncle who may have been identified as having type 2 diabetes. She also had one other non-living maternal uncle who had been diagnosed with type 2 diabetes and Alzhe/Dementia before he died. The paternal aunt is still managing a history of no noted disease.

Cultural Influences

Examination of the well being practices with the client shows that she does not engage in active physical activities. A recommended healthy and balanced practice is always to engage in in least a hundred and fifty minutes of physical activity each week. However , your customer engages in no physical activity. The client personal cleanliness is excellent based upon her capability to clean her hair regularly. Moreover, the client does not smoke cigars, she also cleans her clothes and nail regularly.


The client health status is really as follows:

114% of whole fruits

109% of fruit and vegetables

80% of refined grains

55% of protein, and 59% of cheese dairy.

Moreover, the client eats excess sugar of 114 g per day where the recommended limit is 50 g daily. The client also eats five oz . of grain, a couple of 1/2 glasses of fruit and vegetables, 2 mugs of fruits, 3 glasses of dairy and a few 1/2oz. of protein every day. The risk aspect of the customer nutritional status is that she takes below-recommended protein, cause, and dairy food per day making her facing the risk of becoming nonresistance to disease by consuming below the concentrate on daily calorie limit. (Jarvis, 2012).

Person Client Account

Biographical Data

The client was 49 years of age female individuals, married with three children (two daughters and a single son). The girl with a Black, an American citizen, and a nurse professionally.

Past Well being

The patient previous medical history discloses that the girl with suffering from unhealthy weight with the great hypertension. Even though the patients will not smoke, nevertheless , her vital sign will be:

Weight – 160 pounds

Height – 5’1″

Human body mass index – 40. 23

Eyesight Snellen vision chart:

Proper eye – 20/30

Kept eye – 20/40.

Breathing – 20, 4: you

Blood pressure

Correct arm within a sitting placement – 165/110

Left arm in a sitting placement – 170/115

Temperature – 98. 2 F

Soreness assessment – a frustration

The patient has recently been diagnosed with gestation diabetes when she was between 30 and 39.

Functional Examination

The client loves eating a typical biscuit, preparing powder, and buttermilk of 67 calories a day. Additionally, the client includes a habit of taking appetizers such as chocolates, cookies and vanilla hoagie reaching the 190 calories every day. She also enjoys taking your favorite ice cream and chocolates that reach 428 unhealthy calories a day. Additionally , the client like eating milk, and candy bar getting 235 calories from fat a day. Yet , the patient would not indulge in energetic activity exposing that the lady faces the hazards of hypertension, diabetes, and cardiovascular disease. The assessment in the patient discloses that there is a great interpersonal romance between her and the quick family. (Jarvis, 2012).

Understanding of Health

Donna is known as a registered nurse and aged 49, Caucasian, a nurse professionally. The patient weighs in at 160 pounds, and elevation 5. 1 . ” Your body mass index is 31. 23 and has 3 children using a living mother and non-living father. The health assessment in the patient uncovers there was a brief history of diabetes in the friends and family because her father was diagnosed with diabetes mellitus type 2. The patient has also been diagnosed with gestational diabetes, and her nonliving uncle has become diagnosed with type 2 diabetes. Moreover, we have a history of Alzhe/Dementia in the family. Additionally , your customer does not embark on active exercising making her facing the risk of hypertension. The nutritional qualities of consumers are complete fruits, fresh vegetables, refined cause, protein, mozzarella cheese, and dairy. However , the consumer has the behavior of eating vegetables, dairy, fruits, and protein making facing the risk of being non-resistance to disease by taking foodstuff that is below the target daily calorie limit. However , the client likes eating a cookie, buttermilk, and baking powder. She also enjoys eating cookies, chocolate, vanilla sandwich, your favorite ice cream, and milk.

Physical Assessment

General Overall look

As being set by the previous section, the patient’s age is definitely 49, nevertheless , the client skin tone is mild red with aging spot. The patient likewise uses the assisted equipment for the movement. In addition, her face expression can be symmetrical with comfortable eyes contact. Her mood and her voiced English is acceptable to her education level and age. Moreover, her hearing is usually 100% with no makeup.

Way of measuring

Her fat is your five. 1″ with height 160 cm. Your body mass index is 31. 23. Her vision with Snellen attention chart can be as follows: The patient wears spectacles for the correction of Left eye – 20/40 and Right eye – 20/30. Her respiration measurement is 20, 4: 1 ) Her blood pressure of the correct arm for a sitting position is usually 165/110 and left arm in sitting location is 170/115. The measurement of her temperature can be 98. a couple of F producing her have a pain.

Head and Face

Her hair can be light brownish and curly. Her face looks oblong and shaped. Her provisional, provisory artery can be viewed. Moreover, the movement of the temporomandibular joint is normal with no tenderness. Her frontal joint is firm and encounter no soreness.

Eyes, The ears, Nose, Oral cavity (level a couple of heading)

The person wears glasses to view most periphery. Additionally, the exterior structures of the client happen to be parallel to one another. Her conjunctiva is transparent with obvious underlying and tiny veins. Moreover, her cornea can be smooth with clarity. Her Irish is usually regular with even toque. The students are blue, equal and regular in both sight. Moreover, colour of her disc can be creamy yellow-colored in color with a great oval condition. The artery of her vessels is definitely brighter than the usual vein. Based on her retinal background, every single of her eyes contains a pair of blood vessels and arterial blood vessels. The A: V is usually 2 . a few and asymmetry in the left eye. (Houghton, Houghton, 2009).

Moreover, the person pinna can be bilateral without swelling, not any lesions, without thickening. More important, the voice test demonstrates the patient repeats the whispered word. The nose evaluation shows that her external nose area is symmetrical, smooth stable and company. The patency of the customer is clear, no swelling without polyps. The individual lips happen to be pink, moist and smooth. The teeth will be white, spending free of particles. Her gumline are red in color, and margins are small with no odor. The tongue has green color with the presence of saliva. The customer tonsils are visible, simply no exudate with 1+. The Uvula rises, the cranial nerves IX, X, rises in the midline. Her tongue, the cranial nerve XII, protrudes in the midline, simply no deviation aside and no tremor.

Neck and Neck Vessels

The neck of the sufferer has the shaped pulsation feature with no lumps. There is no indicator of augmentation and pain. Her pulse is clean, moderate and no presence of bruits. There is also no masses and tenderness in her trachea. Furthermore, the patient will not experience pain in the muscles of the neck with typical movement via head to glenohumeral joint, chin to chest with full ROM resistance.

Torso, Posterior, Horizontal, and Anterior

The test reveals that the thorax of the patient is symmetric with downwards sloping steak. Moreover, scapulae are located proportionally within each hemithorax. There is no cyanosis and no lesions. The patient does not have got any tenderness and limps. The CVA tenderness can be not present. Moreover, the breath appears test uncovers that broncho-vesicular, vesicular sounds and the bronchial are suggested. However , the adventitious noises are not indicated.


Quality of the patient’s heart shows no sign of heave or lift. However , the apical impulse of the affected person shows signal of problems

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