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Mrs. Robinson Health History template and rubric revised 1-2020
Fundamentals of Nursing (GNUR 238)
Loyola University Chicago
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Mrs. Robinson’s Health History Packet
Student Name: __________________________
Using the Health History information packet, complete the assessments and template provided to document Mrs. Robinson’s Health History
Review the Mrs. Robinson Health History Information packet o This packet will also be used for the final Care plan assignment Complete the Health History/Assessment Form (template provided)
Review this entire information packet before beginning this
assignment.
This is an individual assignment. It is imperative that you do not collaborate with other students. This needs to be uniquely your own assessment for Mrs. Robinson.
You will be required to submit the following typed (not hand written) electronically on your lab Sakai site. Completed Health History Template / Assessment Form Use this information for care plan assignment later in the semester
Professional submission includes: College level writing Professional Appearance of assignment Name on each page in a header or footer format with page numbers On time submission
10% deduction per day will be deducted for late assignments, no assignment will be accepted more than 5 days late. A zero will be given if the assignment more than 5 days late
Mrs. Robinson Patient Information and Office visit
Mrs. Robinson’s Health History Packet
Mrs. Wilma Robinson Information Packet
Personal
Marital Status Widow for the past 4 years. Married to Frank for 41 years Children/Grandchildren 2 grown sons, Brian and Frank Jr. who live out of the state. She also has 3 grandchildren living out of state Religion “I don’t like organized religion” Hobbies Watching TV, reading, doing crossword and jigsaw puzzles, tending to her two cats Volunteer Service None. Rescues cats when able. Support System Since her husband's death, is mostly isolated. Has become friends with Donna Thomas and reunited with her son, Brian. Ethnicity Caucasian
Financial Status
Job Never worked outside the home Salary Lives on her Social Security of $684 per month Education High school graduate Health Insurance Basic Medicare Housing Owns a small 2 bedroom home in town Debt Lives from one Social Security check to the next. Home is paid for. Taxes are $800 per year. Prescriptions are approximately $120 per month.
Mrs. Robinson’s Health History Packet
Wilma Robinson is a 65-year-old widow who lives alone. Although she has lived in this city for years, she is somewhat socially isolated. She has two adult sons with whom she has limited contact; they live out of the state and rarely call. There are only a few individuals whom Mrs. Robinson considers friends; she does not particularly like most people and prefers the company of her six cats. She has a long history of type 2 diabetes mellitus and hypertension. In recent years, she was diagnosed with atrial fibrillation.
Mrs. Robinson has a known drug allergy to penicillin. Mrs. Robinson does not work; she has very limited savings and relies on Social Security benefits for income. She smokes about 1/2 pack of cigarettes per day and has been a smoker since she was in her twenties. She drinks alcohol “a couple times a year, usually a glass of wine at a special dinner.” Mrs. Robinson does not drive and relies on her friends, neighbors, or the city bus for transportation. She lives near a grocery store and prides herself on being able to get most things she needs without any assistance. She spends most of her time alone at home and occupies herself by watching television, reading, and doing crossword and jigsaw puzzles. Mrs. Robinson has a sore on her ankle that has been there for the past several weeks. It “doesn’t really hurt” but she has been unable to get it to heal. The cashier at the convenience store tells Mrs. Robinson that she should use butter to help heal wounds, because it keeps the wound moist and helps to enhance healing.
Mrs. Robinson’s Health History Packet
Mrs. Robinson decided to follow the advice of her friend (the cashier at the convenience store) and has been applying butter to her wound for about one week. The wound does not seem to be getting any better. In fact, it looks a little worse, so Mrs. Robinson stops the butter treatment. She knows that she should get an appointment with her primary care provider, but when she calls to make an appointment, she is told that the physician she likes is out of the office on vacation for the next 2 weeks. She has heard about a nurse clinic at the Senior Center not far from her home, but she has never been to the center because she does not perceive herself to be old. Mrs. Robinson decides to continue treating the wound herself.
Mrs. Robinson' wound continues to look progressively worse; it now has a yellowish drainage, and the skin around the wound has become red. Her foot also now hurts when she walks on it. She goes to the Emergency Department (ED) early in the morning. After sitting in the waiting room for 4 hours, Mrs. Robinson tells the ED receptionist that she has better things to do than sit in a waiting room all day. She decides to go to the Senior Center just this once to see if the nurse at the clinic will look at her leg.
At the Senior Center Nursing Clinic, Mrs. Robinson meets Peggy, a geriatric clinical nurse specialist, and a student nurse by the name of Maura. Maura starts asking Mrs. Robinson a number of questions that she finds very annoying. Mrs. Robinson says, "Why are you asking me such stupid questions? Can't you see that my leg is hurting?" Maura bursts into tears and leaves the room to report to Peggy that she cannot work
Mrs. Robinson’s Health History Packet
She has received immunizations for Hepatitis B and Tetanus “over 10 years ago”. Her last medical exam was 9 months ago; Dental: “a few years ago”; Eye: 6 months ago, she states “I have really noticed that my eyes are changing”.
Biographical Data (5 pts)
Name: Wilma Robinson Gender: Female Age: 65
Race/Ethnicity: Caucasian Religion: none
Marital Status: Widowed Occupation: none
Financial: Lives on Social Security; $684/month Insurance: Basic Medicare
Family: Two sons out of state (limited contact) and three grandchildren out of state
Health History (20 pts)
Present Health Status:
Allergies (4 points) Medication Penicillin causes rashes Food NKFA; Patient denies food allergies Environmental NKEA; Patient denies environmental allergies Other Patient denies any other allergies
Current Health Conditions (4 points) Type 2 Diabetes Mellitus; diagnosed many years ago Hypertension; diagnosed many years ago Atrial Fibrillation; recently diagnosed Sore on ankle with yellow drainage; has no healed for several weeks
Medications: (12) Name Generic and Trade
Dose and Route Why this patient takes the medication
Glipizide 10 mg po Treatment of type 2 diabetes; controls high blood sugar Captopril 50 mg po Treatment of hypertension; ACE inhibitor Digoxin 125 mcg po Treatment of heart arrhythmia and
Mrs. Robinson’s Health History Packet
support blood pressure Warfarin Sodium 5 mg po Blood thinner, prevents future blood clots
Past Medical and Surgical History: (14 points)
Surgical Patient denies having had surgery
Childhood Illness Patient is unsure of childhood illnesses and dates. Patient states, “I had all those childhood illness”
Hospitalizations Patient denies any prior hospitalization but shares “I
was in the ER and I waited 4 hours and I left”
Immunizations Patient received immunizations for Hepatitus B and
Tetanus “over 10 years ago”
Last examinations Last medical exam was 9 months ago. Dental exam “a few years ago”. Patient shares “I have really noticed that my eyes are changing” after an eye exam 6 months ago.
Accidents or Injuries Patient denies being treated for any accident or injury. Currently has a sore on ankle from bumping into a shovel
Obstetric History Patient has given birth to both sons at home 40+
years ago. Patient states “I am not a big fan of hospitals”
Personal and Psychosocial History: (16 points)
Family and Social Relationships Patient is widowed for 4 years and lives alone. She has 2 grown sons and 3 grandchildren who are living out of state. Her sons do not call nor visit her. Patient has a few friends but does not like most people and prefers being with her cats. The patient spends most
Mrs. Robinson’s Health History Packet
GNUR 238 FOUNDATIONS OF NURING PRACTICE Mrs.
Robinson Health History Rubric
Topic Points Possible Points Earned
Comments
DEMOGRAPHIC DATA TOTAL / Biographical Data 5 points
Present Health Status 20 points
Past Medical / Surgical History 14 points
Personal and Psychosocial History:
16 points
Mrs. Robinson Health History template and rubric revised 1-2020
Course: Fundamentals of Nursing (GNUR 238)
University: Loyola University Chicago
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