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Group assignment Compilation Document Transcript

  • 1. UNIVERSITY OF THE SOUTHERN CARIBBEAN P.O. BOX 175, PORT-OF-SPAIN TRINIDAD AND TOBAGO Compilation of group assignments Presented in Partial fulfilment Of the requirements for Course NAAS323: Advanced Health Assessment Skills in Nursing Practice Lecturer: Mr. Val Tobias Date: 09/11/2013 This group consists of: Tarra Weekes- ID# 2013010022 Sandy Etienne- ID# 201307244 Kelly-Ann Cornibert- ID#201307345
  • 2. Table of content CONTENT PAGE Introduction 3 Body: Assignment 1.1 3-10 Assignment 2.1 10-11 Assignment 3.1 12-14 Assignment 3.2 14-16 Assignment 3.3 16 Assignment 4.1 16-18 Recommendation 19 Conclusion 19 Referencing 20
  • 3. Introduction The three group members came together to complete the required assignments to complete this course. In caring for a patient Health Assessment is one of the first steps a nurse uses as an every tool to gather the information required to attain a diagnosis and develop a plan of care. This would include subjective and objective data which would give information about the patients’ health status, particulars about the patients’ current medical condition, past and current treatment plan, past medical history, biographic data, baseline and updated vital signs, all of which is important and required to create a plan of care. This will assist to better able to gather information required about my patients through health assessment. Competence in health assessment allows a nurse in recognizing pain, emotional disturbances and reaction to treatment. According to Weber & Kelley (2010), Subjective data includes an individual’s emotions / feelings, perceptions, symptoms of an illness, values and beliefs. This data provides clues to possible physiologic, psychological and sociologic problems and thus also plays an integral part of nur sing health assessment, (p. 9), where as objective data is data which is not influenced by personal feelings, interpretations, or prejudice; based on facts; unbiased. This data is factual, unbiased, and unchanged by personal feelings or interpretations. Body / content of assignment Assignment 1.1 1. HEALTH ASSESSMENT 1 DONE BY KELLY-ANN CORNIBERT, PEROFRMED ON / WITH SANDY ETIENNE Sec A. collecting Subjective data Biographical Data Name: Sandy Terralee Etienne Occupation: Registered Nurse Age: 30 years of age Religion: Pentecostal Sex: Female In the case of an emergency please contact: Mary Leonce Date of birth: 27th July 1983 Address: Odsan, Castries, St.lucia Contact numbers:17584512435, 17587133048 Nationality: St.lucian Past Health History Childhood Illnesses: Nil Immunizations up to date (indicate yes or no): yes Relationship: Mother NOK contact #: 4512435, 17587244114
  • 4. Adult illnesses (physical / mental):nil Past Surgeries: nil Past hospitalizations: nil Allergies: (NSAIDS) Current medication use: none Family Health History – Congestive heart failure, diabetes and cardiovascular accident Sec B (objective data) Vital signs Temperature: 98.6°F Spo2: 99% in room air Pulse: 66 Beats per minute Weight: 180 lbs / 81.8kgs Respiratory: 20breaths per minute Height: 5ft 6in Blood pressure: 128/67 Hmmg Neurological / Cognitive Patient is alert, fully conscious and oriented to place person and time Cardiovascular no history of any other medical condition Nutrition / Metabolic Patient has no difficulties with nutritional needs Activity / Exercise Patient is independent and achieves ADLs with no difficulties Sexuality / Reproductive Date of last menstrual period: August 16th, 2013, same irregular, patient has never been pregnant and verbalized having no STIs Objective assessment data done on Miss Sandy Etienne summarized General assessment: during this initial assessment client had appropriate attire and was well groomed. Client gait is steady when ambulating with speech being logical and coherent. Client is fully conscious oriented to place, person and time. Skin integrity appears to be intact with nil lacerations or rash noted. Vital signs were as followed all being within normal range; temperature: 98.6°F, Pulse: 66 Beats per minute, respiratory:
  • 5. 20breaths per minute, blood pressure: 128/67 Hmmg, Spo2: 99% in room air, Weight: 180 lbs / 81.8kgs and height: 5ft 6in Head and Neck: symmetrical features, dark brown hair; clean and odor free, brown eyes, nil deviations in nasal septum, lips pink and moist, moist mucous membranes with no cracks on lips, no extractions noted, nil cavities visually observed, client had metal braces both on lower and upper teeth, no lymph nodes were palpable on or around neck , nil lumps or swelling in the thyroid area, nil difficulty swallowing. Extremities: complete range of motion flexibility was clearly appropriate, normal capillary refill in less than 3 seconds, no pitting oedema, pedal pulse felt and regular, good skin turgor, nil notable abnormalities or discoloration of extremities. Thorax: aligned, round breast, non- tender, nil palpable masses or lumps, normal curvature of spine, bilateral breath sounds, and no creeps or wheezing, s1 s2 heard, nil murmurs or extra heart sounds heard. Gynecological: menstruation is abnormal, 32-60 day cycle, 3-5 day duration Skin: brown, nil bruising and nil open wounds, warm and dry to touch, good turgor Critique of interview between Kelly- Ann Cornibert and Sandy Etienne Interviewer; Kelly-Ann Cornibert Interviewee; Sandy Etienne Introductory Phase In this stage of interview my colleague introduced herself to me. The purpose of the purpose of the interview and assessment was explained. My colleague went further to explain the questions which was part of the assessment to ensure I understood the terminologies. The reasons for taking notes were also explained. The level of confidentiality was explained to me, which made me feel much better. I felt comfortable both physically and emotionally due my colleague’s level of professionalism. My privacy was maintained due to the selected environment. Working Phase In this stage of the interview, my colleague elicited questions about my biographical information, recent, past and present health history including family history. A review of body system was also done systematically at this stage. My colleague listened, used critical thinking and showed levels of being non judgemental when interpret and validates the information we discussed Closing Phase This phase is seen as the termination phase this is where my colleague summarized information obtained during the working phase and validated problems and goals with me. Finally the nurse verified if I had any concerns or questions. 2. HEALTH ASSESSMENT 2 DONE BY TARRA WEEKS, PEROFRMED ON / WITH KELLYANN CORNIBERT Health assessment form
  • 6. Sec A. collecting Subjective data Biographical Data Name: Kelly-Ann Cornibert Religion: Church of Christ Age: 23years Sex: Female In the case of an emergency please contact: Raphael Cornibert Relationship: Father Date of birth: 14th December, 1989 NOK contact #: Address: La-Guerre, Babonneau 1758-7178712 Contact numbers: 1758- 4880682 Interview performed by: Nurse Tarra Weekes Nationality: Saint Lucian Occupation: Registered Nurse Past Health History Childhood Illnesses: Chicken Pox, Asthma Immunizations up to date (indicate yes or no): Yes Adult illnesses (physical / mental): Loss of Lumbar Lordosis Allergies: Shell Fish Family Health History Please tick to indicate history of illness in your family: Diabetes Mellitus Cardiovascular Accidents (Strokes) √ (Paternal) High blood pressure (HTN) √ (Maternal and Paternal) Cancer (please indicate): Nil Sec B (objective data) Vital signs Temperature: 98.60 F Spo2 : 98% in room air Pulse: 72 bpm Weight: 140 lbs / 63.64 kgs Respiration: 18 bpm Height: 5 ft 6 in Blood pressure: 110/84 Neurological / Cognitive
  • 7. Client is alert, fully conscious and oriented to place, person and time Respiratory No respiratory conditions or difficulties Summary of Findings Miss Kelly-Ann Cornibert is a 23yr old female client, of La Guerre, Babonneau, St.Lucia. she is currently a Registered Nurse. During the health assessment session with Miss. Cornibert, I observed that she was a very pleasant, well groomed and co-operative client. She appeared relaxed and well informed of her current health status. Skin: was dark, free of bruises and felt warm to the touch. Respiratory System: despite the client’s previous history of asthma and SOB, nil respiratory distress was observed during the assessment. Cardiovascular: Miss. Coribert is health conscious about nutritional habits. As a result of her predisposing factors to becoming a hypertensive and of developing a CVA, she eats a low- salt/fat diet, to help reduce that high risk. Gynecology: client has a regular menstrual cycle; same is a consistent 28 day cycle that lasts for 5days. She is STI free according to lab results. Currently, Miss. Cornibert’s main complaint is with her musculoskeletal system. She has developed loss of lumbar lordosis, for which is currently being managed with; augmentin 625mg po bd and diazepam 5mg po prn. She reported that the augmentin sometimes gives her diarrhea and the diazepam makes her drowsy, but she is coping well. As a result of this disorder Miss. Coribert is unable to perform strenuous activities, but lives a normal life apart from that. Critique of interview between Tara Weekes (interviewer) and Kelly-Ann Cornibert Interviewer; Tarra Weekes Interviewee; Kelly-Ann Cornibert This interview was well done. Tara Weeks made an appointment to meet at my convenience, in an environment which was mutual to us both. This made me feel comfortable. In the introductory phase my colleague formally introduced herself to me as Nurse Tara Weeks. Here she stated the purpose of the interview and assessment, in which she mentioned that the information would be placed online as an assignment. This I gave consent to. I was informed that my information will be kept in confidence. During the interviews’ working phase, my privacy was maintained as much as possible however due to the location the session was interrupted twice. Excellent communication skill was used. She maintained active listening and good eye contact. Open and closed ended questions were asked to gain required information. I was also given an opportunity to ask questions. I felt comfortable and really appreciate the level of professionalism portrayed by my colleague (Taylor, Lillis and LeMone, 2005).
  • 8. 3. HEALTH ASSESSMENT 1 DONE BY SANDY ETIENNE, PEROFRMED ON / WITH TARRA WEEKES Sec A. collecting Subjective data Biographical Data Name: Tarra Weekes Nationality: St.Lucian Age: 28 years Occupation: Registered Nurse Sex: Female Religion: Roman Catholic Date of birth: 26/3/1985 In the case of an emergency please contact: Janice Weekes Address: Morne-Du- Don Rd, Castries, St.Lucia Contact numbers: 17587146399/ 17584523244 Relationship: mother NOK contact #: 17584523244 Past Health History Childhood Illnesses: Bronchitis Allergies: Pork and associated products Family Health History Please indicate history of illness in your family: Diabetes Mellitus Cancer (please indicate type)√ (lung) Maternal Cardiovascular Accidents (Strokes) High blood pressure (HTN)√ (maternal) Sec B (objective data) General assessment and Vital signs Temperature: 97.6oF Blood pressure: 118/75 Pulse: 84 beats per minute Spo2 : 99% in Room Air Respiratory: 22 breaths per minute Neurological / Cognitive Alert and oriented√ Difficulty speaking / communicating: client is fully conscious Confused: client is fully conscious, congruent conversations
  • 9. History of any Memory loss, Seizures, Fainting spells / dizziness; NIL Cardiovascular No cardiovascular abnormal Nutrition / Metabolic No difficulty eating or drinking Elimination No abnormalities observed or reported. Activity / Exercise Problems performing activities of daily living (ADLs): No problems Sexuality / Reproductive Date of last menstrual period _19th September 21, 2013_______ History of pregnancies Y / N Ever had fertility issues Y / N Objective assessment data done on Miss Tara Weekes summarized General assessment: upon initial head to toe assessment client was appropriately dressed and groomed. Client had steady gait when walking with speech being logical and coherent. Client is fully conscious oriented to place, person and time. Skin integrity intact with nil lacerations or rash noted. Vital signs were as followed all being within normal range; temperature: 97.6oF, Pulse: 84 beats per minute, respiratory: 22 breaths per minute, Blood pressure: 118/75 Spo2: 99% in Room air. Head and Neck: symmetrical features, dark brown hair; clean and odor free, brown eyes, nil deviations in nasal septum, lips pink and moist, moist mucous membranes with no cracks on lips, no extractions noted, nil cavities visually observed, no lymph nodes were palpable on, nil lumps or swelling in the thyroid area, nil difficulty swallowing. Extremities: complete range of motion, normal capillary refill, no pitting oedema, pedal pulse felt and regular, good skin turgor, nil notable abnormalities Thorax: aligned, round breast, non- tender, nil palpable masses or lumps, normal curvature of spine, bilateral breath sounds, and no creeps or wheezing, s1 s2 heard, nil murmurs or extra sounds.. Abdomen: soft, palpable, non- tender, normal bowel sounds heard, nil masses Gynecological: menstrual is a normal cycle, 28 day cycle, 3-5 day duration Skin: brown, nil bruising and nil open wounds, warm and dry to touch, good turgor Critique of interview between Tarra Weekes and Sandy Etienne Interviewer; Sandy Etienne
  • 10. Interviewee; Tarra Weekes Introductory Phase: In this phase Miss.Etienne introduced herself to me. She explained the purpose of the interview and assessment. She reassured me that any information obtained will be kept confidential and I was informed of what will be shared with others prior to termination of interview. I was made comfortable in an enclosed office and the door locked to ensure privacy was maintained. I really appreciated same, as it made me feel more comfortable to open up to her. Working Phase: In this stage of the interview, my colleague exemplified professionalism and was very thorough, especially with the review of the body systems. Her open-ended questions allowed me the express and identify problems which existed or did not exist for each system. Vital signs were assessed and urinalysis was performed all of which were documented. Closing Phase: During this final stage of the interview miss Etienne summarized all the information obtained during the working phase and I validated same. All in all it was a good experience and I complimented her on a job well done. ASSIGNMENT 2.1 INTEGRATIVE HOLISTIC HEALTH ASSESSMENT Biographic data: Name: K. JnB Nationality: St. Lucian Age: 32 years Occupation: Hotel supervisor Sex: Female Religion: Pentecostal Date of birth: 20th June 1981 Current Health Issues: (End Stage Renal Failure) on dialysis Address: La Clery, Castries, St.Lucia Interviewers: (Group members) Kelly-Ann Cornibert Tara Weekes Sandy Etienne Interviewee: K.J - Assessment  Whom would you say make up your support system? My support system is made up of God, and my immediate family (spiritual and physical) including my boyfriend.
  • 11.  Having just discussed your support systems, what is there in your life that gives you internal support? I would say that my internal support comes from God. My belief that there is a higher power and that he will see me through, despite the challenges I may face in this life.  What are your sources of hope, strength, comfort and peace? My main source of hope, strength, comfort and peace comes from my faith and belief in God and support from my spiritual family.  What do you hold on to during difficult times? During difficult times I hold on to my faith in God and his word, my will power to live a life God granted me with and the support from spiritual family and partner.  What sustains you and keeps you going? God’s love for me, my family, work; and my coping abilities, especially the ability to still live a close enough to normal life, despite my current disorder, is what keeps me going.  For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life's ups and downs; is this true for you? Yes, I would agree that my spiritual and religious beliefs help me deal with life’s ups and downs. If it were not for God and my faith in him, I do not know where I would have been in this life.  Do you consider yourself part of an organized religion? Although I attend the Bethel Tabernacle, and I agree to the teaching of the faith (I am spiritually satisfied), I would not say that I belong to the religion. I consider myself a ‘Christian’ and not a ‘bethel.’ I believe that prayer and attending religious service weekly, is most helpful to me personally.  As nurses, is there anything that we can do to help you access the resources that usually help you? I have to admit that I am rather grateful to you three, and the nursing staff at the renal unit. Help is always offered, which makes me feel that I am cared for and this is much more than just doing a job. I feel like all my needs are being adequately met. Thank you.  Would it be helpful for you to speak to a clinical chaplain/community spiritual leader?
  • 12. I feel content with my usual spiritual service, and so an additional clinical chaplain/ community spiritual leader would not be necessary.   Assignment 3.1 Collecting Subjective Data from a client with ESRF (The interview) Biographical Data Name: P.P Address: Morne-Fortune, Castries, St.Lucia Contact #: 1-758-000-0000 Gender: Male Age: 29 Birth date: 13/01/84 Provider of history (patient or other): Patient Place of birth: Saint Lucia Race or ethnic background: African decent Educational Level: Tertiary (Sir Arthur Lewis Community College) Occupation: Self employed as a Disk Jockey(DJ) Significant others or support persons: Parent Reasons for Seeking Health Care: As stated by the patient, he began to notice increased swelling to the ankles; same did not decrease with elevation of the limbs or ice packs as a friend suggested he should do. Patient also reported vomiting for about two months. It is then he decided to seek medical attention. Patient complaint and character- patient complains of prolong vomiting, swelling to the ankle. Patient verbalize when leg is swollen it feels heavy and pulsating whereas vomiting is projective. Describe the onset: “swelling started one month ago and vomiting two months” patient verbalizes his legs gets swollen during the course of the day especially during his activities such as watching television, washing or just his normal everyday activities. Patient verbalizes he mainly vomits late afternoon or anytime he eats a full meal. How long does it last and what alleviated the swelling and vomiting? “The swelling last for a few hrs and is less when I wake up in the early hours and the vomiting lessens when I eat small meals”.
  • 13. Have you ever had this type of swelling and vomiting episodes before? “No I have not had vomiting but the swelling in the legs has been present but not as often”. History of Present Health Concern: Prior to the above mentioned symptoms ( swollen legs), which first began in the year 2011, patient voiced that he had no personal history of prolonged vomiting; however his legs have gotten swollen in the past. Past Health History: Patient verbalized that he is a known diabetic, who has been diagnosed for 22years. He also has diabetic retinopathy and is a known hypertensive. Family Health History: Diabetes mellitus (both maternal and paternal) and Hypertension (paternal) Review of Systems for Current Health Problems; Head and Neck: patient voiced that he (frequently) has headaches, especially if his blood pressure is elevated. Eyes: patient reported that he is visually impaired as he is unable to see in the left eye, and has partial sight in the right. Mouth, Throat, Nose, and Sinuses: patient verbalize his mouth and throat feels dry. Thorax and Lungs: patient reported he occasionally has difficulty breathing Heart and Neck Vessels: patient voiced that he recently developed heart palpitations as a result of side effects of his use of amlodipine (antihypertensive drugs) Peripheral Vascular: patient voiced he had difficulty ambulating only when his leg is swollen it limits his movements. Abdomen: patient verbalizes having abdominal pain hours after vomiting and heartburn.. Lifestyle and Health Practices (as voiced by patient): • Diet (Renal/diabetic diet). Stick fluid intake. • Decrease in sporting activities, as a result of decrease in vision and constant tiredness and shortness of breath. • Decrease in socialization, as he is unable drive to events because of decrease in vision. Voiced that he also feels uncomfortable around others who he considers ‘normal’ as he fears that they will see him as being abnormal. Developmental Level: Patient is a young adult who voiced that his current condition limits him to living the normal life that he was use to, prior to his disorder. He believes that his physical limitations are especially attributed to his vision loss and voiced that he fears going completely blind one day.
  • 14. Present complaint • • Swollen lower extremities Prolong vomiting Nursing diagnosis based on findings • • Altered mobility related to edematous extremity as evidence by 3+ pitting edema noted in lower extremities Acute pain related to excessive vomiting as evidence by patient verbalizing discomfort after vomiting. Assignment 3.2 Normally the spleen acts as a filter in the human body filtering old red blood cells from the blood as it passes through the spleen continuously. In individuals with sickle cell disease (Hg SS disease) the repetitive sickling of the red blood cells and local infarction eventually causes scarring, splenic congestion which results in fibrosis, and splenomegaly and a non-functional spleen (Silvestri, 2008). Pallor, lethergy and or acute splenomegaly, may be the first clinical signs of a potentially life threatening splenic sequestration crisis which refers to an acute condition of intrasplenic pooling of large amounts of blood causing the blood-filled spleen to become enlarged possibly filling the entire abdomen (Silvestri, 2008). Collecting Objective Data from a client with splenomegaly secondary to sickle cell disease (SCD) Biographical Data Name: J.T. Address: Morne Du Don, Castries, Saint Lucia Contact #: 1-758-000-0000 Gender: Male Age: 6 years Birth date: 19/12/2001 Provider of history / information (patient or other): Patient and mother S.T. Place of birth: Saint Lucia Race or ethnic background: African decent Educational Level: Primary School. Occupation: Student Significant others or support persons: Parents Reasons for Seeking Health Care:
  • 15. Mother states that infant has been voicing having pain in the abdomen. Infant has decreased appetite and is less active, also presenting with fever for two days (2/7) History of Present Health Concern: Mother states that both herself and infant’s father has sickle cell trait (AS) however the child is a known sickle cell disease (SS) patient. This is also seen through evidence of old notes available. Review of Systems for Current Health Problems; Skin, Hair, and Nails: on inspection nil hair loss or current nail infections noted, nil rashes noted, however small lesions noted on extremities. Mother voiced that in playing this occurred and bleeding was observed. Head and Neck: Nil deviations noted. Ears: Ears symmetrical to eyes and face. Eyes: Infant’s field of vision and depth perception is functioning correctly based on basic eye exam. Mouth, Throat, Nose, and Sinuses: Lips pink and moist. Nil deviations noted. Thorax and Lungs: Equal chest rise noted. On ascultation of the lungs clear bilateral air entry heard. Breasts and Regional Lymphatics: Nil masses noted. Heart and Neck Vessels: Normal heart sounds ascultated, S1 ans S2. Nil abnormal sounds heard. Decreased hemoglobin level of 7.5mg/dl noted on lab. Peripheral Vascular: Nil edema noted. Abdomen: Abdomen appears edematous. Decreased bowel sounds heard in all four quadrants. Patient has pain on palpation of the abdomen due to facial grimace, guarding of area and crying. Large mass in the upper left quadrant of the abdomen noted. Patient has decreased appetite due to an enlarged spleen pressing against stomach. Male Genitalia: Nil abnormalities noted. Testes are descended, foreskin retractable. Amber coloured urine voided, nil sediments noted. Anus, Rectum, and Prostate: Nil abnormalities noted. Musculoskeletal: Patient experiencing moderate to severe pain at joints and generalized body, patient looks fatigue. Neurological: Infant is awake, alert, fully conscious and oriented to time, place and person. Patient observed to be gloomy, due to pain. Present complaint Infant is a known sickle cell disease patient presenting with abdominal crisis, pain at joints and generalized body decreased appetite. Mass noted on palpation of abdomen at location of spleen. Nursing diagnosis based on findings • • Chronic pain related to medical condition (sickle cell disease) evidence by facial grimace, and crying. Risk for infection related to decreased immunity evidence by diminished function of the spleen. Conclusion
  • 16. This assessment done by the above mentioned group members consist of objective data obtained by using the steps in assessment: inspection, palpation, percussion, auscultation. This data will provide us with valid information or evidence to determining a possible diagnosis for the patient. This will better able us to provide adequate care to him. We are thankful to T.J and his mother who allowed us to do this interview as part of our requirements of this health assessment course. Assignment 3.3 According to Silvestre, (2008), Osteoarthritis is a progressive degeneration of the joints as a result of wear and tear. This condition also causes bone build-up and the loss of articular cartilage in peripheral and axial joints. p. 1087. Patient introduction: - 46year old female (W.P), with a previous health history of osteoarthritis (degenerative joint disease). This client was selected when she attended the orthopaedic clinic. Her chief complaint was pain in the lower limbs mainly in the knees for eight days Present health history; Hypertension, ( controlled) and osteoarthritis. Based on COLDSPA the assessment was as followed, (smu.edu, 1998). CHARACTERISTIC: Describe the sign or symptom. How does it feel and look? Patient appeared to have limited range of motions in the lower extremities and would usually walk very slow to avoid more pain. Patient verbalized that the knee looks swollen and tender to touch. ONSET: When does the pain begin? Patient verbalized that pain begins with slight motion or even at rest. LOCATION: Where is the pain and does it radiate? Pain is in the knees and seldom in the hands. DURATION: How long does it last? Does it recur? Pain last for a few weeks to months. Patient verbalized that pain recur after six months based on his activity level or job. SEVERITY: How bad is it? Patient verbalized out of 10 being the worse pain of his life that it measured 9 however it usually fluctuates based on the weather changes and how much he walks. PATTERN: What makes it better? What makes it worse? Sitting for a prolong time makes it worse when trying to walk or stand because swelling usually appears. Having physiotherapy and maintaining weight within normal range assist the patient in reducing stress on her joints. ASSOCIATED FACTORS: What other symptoms occur with it? Other factors which would appear would be swelling in the knee area, sometimes nodules appear in the joints of the hands. Nursing diagnosis: Impaired physical mobility related to musculoskeletal disorder as evidence by swelling in the knees and pain when standing or walking. Assignment 4.1:
  • 17. Biographical Data Name: A. St. C. Address: Desrameaux, Gros Istel St. Lucia Contact #: 1-758-000-0000 Gender: Female Age: 78 years Birth date: 21/08/1935 Provider of history / information (patient or other): Patient and daughter M. St. C. Place of birth: Saint Lucia Race or ethnic background: African decent Educational Level: High school. Occupation: Retired. Significant others or support persons: Children Reasons for Seeking Health Care: Patient and daughter stated that A. St. C. has begun to slow down in her activities of daily living. Her appetite and hearing abilities have become impaired, due to the decrease in appetite, she has lost a significant amount of weight. History of Present Health Concern: Prior to the above mentioned symptoms, which began two (2) months ago, patient voiced that he had no history of serious illnesses. There has been no family history of diabetes, high blood pressure, kidney failure or cancer. Past Health History: Patient verbalized that she has been diagnosed with arthritis two (2) years ago in 2011. General appearance: Based on appearance, patient can be given an approximate age of 85 years. Same observed to be alert, fully conscious and oriented to time, place and person. Patient is cooperative, however is ill looking. Vital Signs: Temperature: 95.60F, blood pressure118 / 76, pulse rate: 76bpm, same regular, respiratory rate: 22bpm, random blood sugar: 90mg / dl, current weight: 54.1kgs. Skin, Hair, and Nails: Hypo and hyper pigmentations of skin noted. Skin silky, moist and wrinkled, same cool to touch. Nil lesions or rashes reported or noted. Alopecia noted at hair midline. Nil eruptions, scars, masses, or nevi seen or verbalized by patient or daughter. Head and Neck: Size appropriate for body, nil evidence of trauma noted, nil tenderness noted at sinuses), nil masses noted. Ears: Gross hearing noted to be impaired as hearing test was failed. Daughter voiced that patient has difficulty hearing and when speaking to her, she has to repeat what was said loudly. Eyes: Eyebrows and eyelids symmetrical. Nil conjunctival inflammation noted. Nil scleral icterus voiced by patient. Pupils bilaterally reactive to light @ 3mm. Nil abnormalities seen or voiced by patient. Mouth, Throat, Nose, and Sinuses: Nil deformities or septal deviation noted. Mucous membrane pale. Nil inflammation, polyps, bleeding and or discharge. Hypo and hyperpigmentations of skin noted. Patient noted to have dentures. Nil inflammation, and bleeding of mouth noted or voiced. Tongue pale pink, with light coating of food substance, with halitosis noted. Tonsils not inflamed same symmetrical with nil exudates. Thorax and Lungs: Bilateral air entry noted with equal, adequate lung expansion. Thorax symmetrical in excursion. Nil intercostal retractions, rib tenderness and chest wall masses noted. Bronchovesicular sounds auscultated with nil creps, rhonchi, crackles or wheezing heard.
  • 18. Breasts and Regional Lymphatics: Right breast slightly bigger than left. Nil Tenderness, masses of discharge noted or reported by patient. Heart and Neck Vessels: Apical pulse ausculated, same 78bpm bounding, S1 and S2 heard with nil S3 and S4 sounds, rubs, or gallops heard. Peripheral Vascular: Patient voiced she has difficulties ambulating and has cramps in lower limbs when sitted for long periods. Slight edema noted to lower limbs. Abdomen: Symmetry in shape, nil tenderness or masses palpated. Decreased bowel sounds auscultated in all four (4) quadrants. Daughter voiced patients has decreased appetite. Female Genitalia: Decrease in sexual desires voiced by patient. Patient has urinary incontinence, however has scanty urine. Anus, Rectum: Nil abnormalities noted or voiced by patient. Musculoskeletal: Patient voiced having difficulty ambulating due to pain in her joints. Neurological: Increased sleep. Daughter voiced that patient is generally a cheerful individual and has learned to accept her limitations. A. St. C. voiced however, that she sometimes goes into a state of depression, as a result of loss of independence and having to depend on her family. Lifestyle and Health Practices (as voiced by patient): • Semi-solid diet. • Decrease in ADLs, as a result of increased pain in joints. • Decrease in socialization, as she is unable to get to events due to difficulty ambulating. Patient voiced that she also feels uncomfortable around others who she considers ‘normal’ as she fears that they will see her as being abnormal an dependent. Family / community assessment: Health Issues: o Immunization rates for individuals in the community and family are up-to-date. o There is an increased rates of births to single mothers under the age of 18 years. Economic Conditions: o There are increase poverty rates in the community however the family is able to afford. o There are schools and one nursing home which provide a number of students and elderly persons reduced-price of free lunches. o There are an increase number of unemployed persons in the community. Family Issues: o Increased juvenile incarceration rates. There is an increased in elderly persons being abandoned by their families
  • 19. Recommendations 1. Nurses should always assess the risks and benefits (identifying which people may be affected and how they may be affected) of the patients they come into contact with based on their category such as neonatal or elderly. 2. Nurses should ensure that the phases of the interview are established: introductory, working and closing phase to ensure patients are comfortable and the interview questions are adequate to obtain relevant information needed. 3. Nurses should keep abreast with continuing education to ensure adequate care is given during assessment phase and proper procedures are used. 4. Nurses must always monitor and evaluate patient outcome and perform referrals when appropriate. 5. Reviewing decision-making through the process of assessment is critical. 6. Planning to set care priorities and goals. Goal-setting should follow the SMART system and COLDSPA, i.e. the goal will be specific, measurable, achievable and realistic, and timeoriented, and Character, Onset, Location, Duration, Severity, Pattern and Associated Factors (illness assessment) Conclusion This compilation was indeed a challenge. Nurses have possessed a unique level of knowledge when providing care. Obtaining a concise and effective health history and physical exam takes practice. It is not enough to simply ask questions and perform a physical exam. As the patient’s nurse, we must critically analyze all of the data you have obtained, synthesize the data into relevant problem focuses, and identify a plan of care for your patient based upon this synthesis. As the plan of care is being carried out, reassessments must occur on a periodic basis. The frequency of reassessments is unique to each patient based upon their diagnosis.
  • 20. The ability of the nurse to efficiently and effectively obtain the health history and physical exam will ensure that appropriate plan of care will be enacted for all patients (Jarvis, 2008). Reference listing Anandarajah, G., (2001); Examples of Questions for the HOPE Approach to Spiritual Assessment. Retrieved on October 3rd 2013 from http://www.aafp.org/afp/2001/0101/p81.html C. Jarvis, (2008). Physical examination and Health Assessment 5th ed. Saunders Elsevier Jarvis, C. (2008). Physical examination and health assessment, (5th ed). St. Louis: W.B. Saunders. Kozier, E. & Berman, S. (2004), Fundamentals of Nursing Concepts, Process and practice, (7th ed.) Upper Saddle River: NJ: Pearson Prentice Hall Silvestri. L.A. (2008), Comprehensive review for NCLEX – RN Examination (4th ed) Saunders, St. Louis, Missouri, 63146. Weber, J., & Kelley, H., J. (2010). Health Assessment in Nursing (4th. ed.). Philadelphia: Wolters Kluwer Lippincott Williams & Wilkin Royal College of Nursing, (2011); Spirituality in nursing care- a pocket guide. Retrieved on October 3rd 2013 from http://www.rcn.org.uk/__data/assets/pdf_file/0008/372995/003887.pdf Smu.edu, (1998); Pain assessment. Retrieved 25th October 2013 from http://jxzy.smu.edu.cn/jkpg/UploadFiles/file/TF_0692815164_pai%20assessment.pdf