History Taking Strategies

History 1

History-Taking Strategy Activity

Keith Lathrop

University of Phoenix

NUR 420 - 3/20

Amanda Brooks RN, FNP

March 31, 2007

History 2

Mr. Smith is a 56 year old male patient with COPD. He is retired from the railroad and

resides in a long term care facility. He is a widower and the only family in the area is his son who lives a short distance away and spends time with his father two or three days a week. With the exception of a few other minor health problems, somewhat advanced COPD is his only significant disease which has caused him to be dependent upon low flow oxygen. Mr. Smith remains active at his LTC facility and participates in daily activities as well as occasional short trips with his son. He states he has never been "into religion all that much" but enjoys playing cards watching sports on television.

Continued slowing of physiological functions and beginning loss ofÐ'...balance and coordination (Schuster & Ashburn, 2002) are normal expectations for the middle age adult. As for Mr. Smith's physical milestones, he is well developed and able to perform all of his activities of daily living independently. However, he does tend to have some dyspnea on exertion (DOE) and states that it "takes me longer than it used to" to perform activities such as getting dressed in the morning but acknowledges that frequent rest periods and pursed lip breathing have allowed him to adapt in the last few years. He also appears well nourished and says that his appetite is ok, but complains that he feels like it takes him "too long to eat" at times since he has to take frequent breaks for mild shortness of breath. As compared with other in Mr. Smith's age group, he is able to perform all expected or anticipated activities although it does require that he take more time to accomplish these tasks because of his respiratory status.

History 3

Gross and fine motor skills begin to be affected in the middle-aged adult as well due to "atrophy of muscle tissue, decalcification of bone and decrease in bone density as well as degenerative changes in the brain" (Schuster & Ashburn, 2002). Mr. Smith seems to have gross motor skills intact as evidenced by his ability to bath, eat, dress himself and ambulate independently. He states that he "feels weak at times" and "can't do things the way I did them 20 years ago" but has adapted well and performs as anticipated. Fine motor skills appear to pose a small problem as he admits to having trouble with buttons on his shirt and feels "shaky" sometimes; however, he still plays cards three nights a week