Conduct a family assessment using the Friedman Family Assessment found in Week 9. Develop a health genogram for this family. See the example of a genogram found in the Estes Health Assessment text. Link found in Week 9.
Assignment Criteria:
Write a scholarly paper and include the following:
1. Identification of the health issues that are present in this family. Support your identification with from information in your assessment.
2. What, if any, genetics risks are present?
3. What are future health risks for this family?
4. Compare those findings with the topics and objectives and preventative measures found for Healthy People 2020.
5. Identify a need for a community health nurse to begin health promotion for this family? Develop a plan for this family to reduce their health risks.
6. Submit the following: the completed family assessment, the family?s health genogram, and your paper with a health promotion plan for the family.
7. Use at least three peer-reviewed sources to support you plan.
FAMILY ASSESSMENT FOR GENOGRAM INFORMATION BELOW
BIOGRAPHICAL DATA
Patient Name Julio Gonzalez, Jr.
Address 4530 176th Place, SE
Bellevue, WA 98006
Phone Number H-parents (206) 603-9122
H-school (602) 626-6109
Date of Birth January 27, 1988
Birthplace Bellevue, WA
Social Security Number 222-56-8765
Occupation Student
Insurance Blue Cross/Blue Shield
# 987-65-4321, Group No. 108
Usual Source of Health Care Pediatrician saw pt throughout childhood; he retired and records were lost in a fire last yr
Source of Referral Parents
Emergency Contact
Julio and Maria Gonzalez
(206) 603-9122
SOURCE AND RELIABILITY OF INFORMATION Self; reliable historian
PATIENT PROFILE
Age 21
Gender Male
Race Hispanic
Marital Status Single
REASON FOR SEEKING HEALTH CARE ?I am home on winter break from college, and I am planning on going to Belize on my spring break my fraternity brothers and I need to get whatever shots are necessary.?
PRESENT HEALTH Pt describes himself as a healthy college student any medical problems
PAST HEALTH HISTORY
Medical History Seasonal allergies since started college 3 yrs ago; denies any chronic/serious illnesses
Surgical History Hydrocele repair and inguinal herniorrhaphy age 7 sequelae
Allergies
NKDA
Medications
Prescription Desloratadine 5 mg po daily PRN
OTC Ibuprofen for H/A PRN
Communicable Diseases Denies STD, never been tested for HIV
Injuries and Accidents Scalp sutured age 4 when fell backward off rocking chair, no loss of consciousness, no sequelae
Special Needs Denies
Blood Transfusions
Denies
Childhood Illnesses Chickenpox age 6 sequelae; denies MMR, diphtheria, pertussis, polio, scarlet fever
Immunizations ?My parents say I am up to date; I had a meningitis vaccine before I started college.?
SOCIAL HISTORY
Alcohol Use
Beer on the wkends at frat parties, quantity varies; sometimes gets drunk hangover in AM; denies drinking and driving; denies passing out; believes alcohol use is ?typical? for college student
Tobacco Use Denies
Drug Use Tried marijuana once at a party freshman yr at college; denies use of anything since then
Domestic and Intimate Partner Violence Denies
Sexual Practice Not sexually active nor ever has been; believes he should remain abstinent until marriage
Travel History Cancun last yr on spring break
Work Environment N/A
Home Environment
Physical Environment Lives in old fraternity house frat brothers; has kitchen and laundry facilities; has cleaning people for common area; rooms 2 other brothers; smoke detector is usually disconnected
Psychosocial Environment Feels safe in house/neighborhood
Hobbies and Leisure Activities Community service fraternity, intramural sports program Interfraternity Council, hanging out friends
Stress
School, looking for a job graduation in May
Education College senior majoring in Environmental Science
Economic Status Parents pay some tuition and living expenses, has college loans he will need to repay
Military Service Denies
Religion Family is Jehovah?s Witnesses, pt currently not involved church while at school
Ethnic Background Hispanic, grandparents were from Mexico
Roles and Relationships Only child in a large, extended family; likes to get together family when he is home on breaks; feels like he can talk to his parents
Characteristic Patterns of Daily Living ?Wow! That varies so much it is hard to say. I can say that I eat at least 2 meals a day, I work out daily, I study, and I play a lot of foosball.?
HEALTH MAINTENANCE ACTIVITIES
Sleep Tries to get 8 hrs but it can be 4 hrs if there is a party on Thursday night or other social event
Diet Eats at least 2 meals daily at student dining hall; does not follow any particular diet
Exercise Basketball, running, racquetball, or lacrosse at least 60 min daily
Stress Management
Exercises, plays foosball
Use of Safety Devices Wears seat belt
Health Check-ups Last exam was his pre-college physical; uses student health when sick; dentist q summer
REVIEW OF SYSTEMS
General High energy levels, healthy, denies recent illness
Skin Uses sunscreen when outside more than 1 hr
Denies rashes, itching, ? in skin pigmentation, ecchymoses, pruritus, ? in moles, sores, lumps, ? in skin texture, body odors, acne
Hair Denies alopecia, hirsutism, dandruff, pediculosis, scalp lesions
Nails Denies ? in nails, splitting, breaking, onychomycosis
Eyes Denies use of glasses/contacts; doesn?t wear sunglasses on bright days Denies blurry vision, photophobia, ? tearing, diplopia, eye drainage, blood-shot eyes, pain, blind spots, floaters, flashing lights, halos around objects, glaucoma, cataracts; can?t remember when eyes were last examined
Ears Denies hearing deficits, hearing aid, pain, discharge, vertigo, tinnitus, earaches, infection; ear pierced last yr sequelae
Nose and Sinuses SAR per PHH, averages 1?2 colds/yr, denies d/c, itching, postnasal drip, sinus pain, polyps, obstruction, epistaxis, ? in sense of smell; ? orthodontics
Mouth Brushes teeth 1?2 ?/d, denies toothache, tooth abscess, caries, bleeding/swollen gums, sore tongue, ? in taste, lesions, ? in salivation, halitosis, difficulty chewing
Throat and Neck Denies hoarseness, ? in voice, frequent sore throats, dysphagia, pain/stiff-ness, goiter
Breasts and Axilla Denies ? in size, pain, tenderness, d/c, lumps, dimpling, rash
Respiratory Denies sputum, sneezing, wheezing, hemoptysis, pneumonia, emphysema, EIA, asthma, TB
Cardiovascular and Peripheral Vasculature Denies paroxysmal nocturnal dyspnea, heart murmur, palpitations, CP, syncope, edema, orthopnea, cold hands/feet, leg cramps, intermittent claudication, varicose veins, thrombophlebitis, anemia, rheumatic heart disease
Gastrointestinal Regular bowel habit: BM q AM, soft and brown, denies vomiting, diarrhea, constipation, melena, ? in stool color, hematemesis, ? flatulence, belching, heartburn, regurgitation; dysphagia, abdominal pain, jaundice, peptic ulcers, hemorrhoids, hepatitis, gallstones, umbilical hernia
Urinary Denies ? in urine color, voiding habits, hesitancy, urgency, frequency, nocturia, polyuria, dribbling, loss in force of stream, bedwetting, suprapubic pain, kidney stones, incontinence, UTIs
Musculoskeletal Denies bony deformity, weakness, ? ROM, swelling, sprains, dislocations, gout, arthritis, herniated disc, back pain
Neurological Denies ? in balance, incoordination, loss of movement, ? in sensory perception, ? in speech, ? in smell, tremors, syncope, loss of memory, involuntary movement, loss of consciousness, sz, weakness, vertigo, tremors, tics, CVA
Psychological Anxious about graduating from college in 4 mos
Denies nervousness, difficulty concentrating, mood changes, depression, suicidal thoughts
Male Reproductive Denies impotence, testicular/penile pain, penile d/c, inguinal hernia
Nutrition Usual and present weight 82 kg (176 lbs)
Food preferences: hamburgers and fries
Food dislikes: brussel sprouts and peas
Denies food intolerances
Consumes 2?3 caffeinated drinks daily (sodas)
Endocrine Denies exophthalmos; ? in size of head, hands, or feet, cold intolerance, polyuria, polydipsia, polyphagia, ? in body hair distribution, goiter
Lymph Nodes Denies enlargement or tenderness
Hematological Blood type O+
Denies easy bruising/bleeding, anemia
