Lernbaustein 6 Anamnesegespräch - Pflegeanamnese

Summary

In this transcript, Nurse Monika conducts an intake interview with Mrs. Gudrun Werner, a 70-year-old woman who has a history of breast cancer, diabetes, and hypertension. Mrs. Werner shares her medical history, including her coronary artery disease diagnosis, previous surgeries, and challenges such as swelling in her arm. She also discusses her struggles with sleep, mild depression, and occasional pain. Nurse Monika gathers important information, including emergency contact details, allergies, medications, and daily needs like dietary preferences and incontinence products. The interaction highlights the compassionate care and detailed assessment necessary for personalized treatment.

Takeaways

• 😀 The nurse, Schwester Monika, introduces herself and explains that she will be conducting the nursing admission interview with Mrs. Werner.
• 😀 Mrs. Werner mentions that her initial diagnosis is coronary artery disease, which causes her chest pain and shortness of breath.
• 😀 Mrs. Werner is 70 years old and was born on July 26, 1948. She is called Gudrun by her family and was asked for her first name during the interview.
• 😀 Mrs. Werner's emergency contact is her son, Wolfgang Werner, who lives in Erfurt and is expected to visit her during her stay.
• 😀 Mrs. Werner shares her medical history, which includes a past breast cancer diagnosis, surgery for mastectomy, and chemotherapy, which affected her lymph nodes.
• 😀 The nurse expresses sympathy for Mrs. Werner's health history and reassures her that her current situation is not as severe.
• 😀 Mrs. Werner reports no need for mobility aids at home, although her doctor offered a walker due to her shortness of breath.
• 😀 Mrs. Werner does not use hearing aids, glasses, or other medical devices but does use a full denture for both upper and lower teeth.
• 😀 Mrs. Werner is diabetic and has managed it well with her doctor's guidance. She also experiences mild hypertension, which has improved over the years.
• 😀 Mrs. Werner occasionally suffers from sleep disturbances, including waking up sweating at night and uses sleep medication once or twice a month, following advice from her doctor.

Q & A

What is the main reason Frau Werner is currently in the hospital?

Frau Werner is in the hospital due to symptoms related to coronary heart disease, such as shortness of breath and chest pain.

What medical condition did Frau Werner have in the past?

Frau Werner was diagnosed with breast cancer in 2010, which required the amputation of her right breast and lymph node removal. She also underwent chemotherapy and radiation.

How did Frau Werner describe her current physical abilities at home?

Frau Werner stated that she is able to move around well at home without the need for a cane or walker, despite experiencing occasional shortness of breath.

Does Frau Werner use any assistive devices?

Frau Werner does not use assistive devices like glasses, hearing aids, or a wheelchair. However, she wears a full dental prosthesis.

What is Frau Werner’s medical history regarding diabetes?

Frau Werner has been diagnosed with diabetes for about five years. However, her doctor has managed it well, and she has few issues related to it.

What lifestyle choice does Frau Werner follow to manage her health?

Frau Werner follows a predominantly vegetarian diet, which she prefers and hopes to continue while in the hospital.

Does Frau Werner experience any sleep disturbances?

Yes, Frau Werner experiences sleep disturbances, including waking up frequently during the night and sometimes sweating. She occasionally takes a sleeping pill, but only once or twice a month.

Has Frau Werner had any issues with incontinence?

Yes, Frau Werner has urinary incontinence, which was diagnosed by her doctor. She asked about getting pads during her hospital stay.

What medications does Frau Werner take regularly?

Frau Werner takes medications for diabetes and hypertension regularly, but she does not take regular pain medications.

What advice did the nurse give Frau Werner regarding her valuables?

The nurse advised Frau Werner to give her valuables, like her phone and jewelry, to her son for safekeeping, as theft has occurred in the hospital before.