Health History and Physical Assessment RUA

Health History and Physical Assessment RUA Jenna Anderson Chamberlain College of Nursing NR 304: Health Assessment 2 April 2017 Professor Moersch Demographic Data JR is a 57-year-old Caucasian male. He currently lives in St. Charles, Missouri in a suburban area with his family. He lives with his wife, son, and daughter. He also has another daughter who lives close by. JR works as an electrical engineer for MasterCard. His job does not require any dangers any body systems, although, he does live a sedentary lifestyle. Reason for Seeking Care JR came into the office for an annual check-up following his diagnosis with kidney cancer and removal of his left kidney. He noted fatigue and some blood in his urine related to his diagnosis. JR decided he needed to have check-ups regularly as a preventative measure for any other illnesses that may become present during his lifetime. His urologist recommended he see his primary care physician yearly to prevent any further complications with his present illness and prevent any other illnesses. Present Illness JR present illnesses are anxiety and depression. Since the death of his father and his diagnosis with cancer he notes that his depression and anxiety have gotten worse. He states “Now that the surgery to remove my kidney is over and I am cancer free I may be a little less anxious, but I am still worried.” The main needs of the patient are to address his feelings about his recent cancer diagnosis and educate him on further prevention and signs and symptoms of any complications. Perception of Health JR thinks that being healthy means being free of diseases as well as maintaining a healthy weight for the individual. He states that people remain healthy be exercising regularly and eating a well-balanced diet. JR knows he is not the healthiest because he does not exercise regularly. He ………………………………….CONTINUED……………………………………