Health History components
The person, John, is a 20-year-old male in college.
Perception of health
John is a healthy looking male.
Past Medical History (including medications, allergies, and vaccinations/immunizations)
John has undergone through normal immunization given to children. He is also immunized against hepatitis and periodically takes a shot against the flu. He has been treated against severe allergic rhinitis and takes antihistamines to manage the condition.
Family Medical History
The father has no history of major medical complication. The mother, however, suffers from allergic conditions such as hay fever, high blood pressure, and allergic rhinitis as well. She has undergone Desensitization Therapy with Intravenous Gammaglobulin (IVIG) to manage most of the seasonal allergies.
Review of Systems; Head-to-Chest
There is no significant negative sign except for swollen adenoids, stuffy nose, and inflamed nasal cavities.
This does not apply, as John is a fully-grown adult. He appears to have achieved all growth milestones from birth to the current stage.
John is a white male who subscribes to the social ethics of the western worldview. He believes in modern medicine and periodically goes for a checkup just to make sure his health condition is top notch.
Psycho social considerations
John is a healthy man who exercises regularly. During summer, he works for local companies or volunteers in a home of the terminally ill. His general attitude to the life is active, and that is why he takes an annual medical exam with the view of maintaining his current state of good health. He has no history of mental illness or depression. However, once in a year, he spends a few months in the county assisting his grandfather in his farm. During that period, he is exposed to domestic animals, plants, and other things common in a farm. He visits a few months after the planting season and before harvesting. He is attentive, and no discernable Anhedonia or Blunted affect.
Priority for evaluation
The most important areas for assessment are Eye, Nose, and Throat. The three areas are a priority because they are possibly linked in some way to the current condition of allergic rhinitis that John is suffering from.
Two teaching/learning need priorities for this individual
He needs to learn how to maintain health via exercise and how to avoid allergens. Although he is active and leads a healthy life, there is a need to train him on how to maintain his current good choices. It is important for him to learn because as a young person, he might fall into bad food choices thereby negating the benefits he has achieved so far. Secondly, John needs to manage his condition effectively because avoiding allergens such as pollen, dust particles, and pet droppings during a particular period of the year or when he is at home relaxing is important in keeping his allergy under control.
The family is a good source of support. When they understand his condition, they will remind him to live responsibly. The healthcare system is perhaps the most valuable resource. It is through the healthcare system he has achieved help so far the importance of such support cannot be gainsaid.
According to the American Nurses Association, nurses are advocates for their patients, and therefore they must maintain communication with patients with them. This communication takes the form of therapeutic communication, which is the face-to-face interaction between the patient and healthcare workers, and the goal is to advance the physical and emotional wellbeing of the patient.
During my interaction with John, I put to good use the therapeutic communication techniques and strategies I have learned in class. The environment took place in his room as John is a student and lives in the dorm. I found him alone, and he was welcoming. After a brief introduction and stating the goal of my visit, John did not appear comfortable, and therefore I used a technique called self-disclosure to put him at ease. I narrated to him a personal health problem of nose bleeding that I have struggled with and the intervention I have received so far in from my healthcare provider. That information immediately made him comfortable as it role modeled the behavior that I expected during the interaction.
Other techniques I used include active listening, showing empathy, maintaining eye contact, humor, giving information, clarification, giving general leads, seeking information, verbalizing the implied, and validation. Consequently, the interview was a huge success as I got all the information that I needed.
The primary barrier to the communication was the unwillingness of John to share health information. However, as I have stated, I used self-disclosure to model behavior. Another problem was that John assumed I understood some of the things he was implying. I overcome the problem by verbalizing what I thought he meant and therefore giving him an opportunity to clarify.
The interview took long due to several interruptions. John wanted to play games or chat with friends on social media. Therefore, I felt like my preference was an intrusion. Keeping John interested in the interview was not an easy thing. Our interests at that particular moment did not appear to be congruent because while I wanted information, John did not think it was that important. What I wish I obtained was further details of maybe another condition he might have. Next time, I think I will suggest we meet in a location without too much interruption.