NR 302 – Health Assessment

NR 302 – Health Assessment

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Chamberlain College of Nursing NR 302 – Health Assessment

The Health History

 

Student:                                                   Date: 2/7/2015

   

PURPOSE

BEFORE ANY NURSING PLAN OF CARE OR INTERVENTION CAN BE IMPLEMENTED OR EVALUATED, THE NURSE CONDUCTS AN ASSESSMENT OF THE INDIVIDUAL THAT INCLUDES BOTH SUBJECTIVE AND OBJECTIVE DATA. THE DATA COLLECTED IS USED TO DETERMINE AREAS OF NEED OR PROBLEMS TO BE ADDRESSED BY THE CARE PLAN. THIS ASSIGNMENT WILL FOCUS ON COLLECTING SUBJECTIVE ASSESSMENT DATA, SYNTHESIZING THE DATA, AND IDENTIFYING HEALTH/WELLNESS PRIORITIES. THE PURPOSE OF THE ASSIGNMENT IS TWO-FOLD:

TO RECOGNIZE THE INTERRELATIONSHIP OF SUBJECTIVE DATA (PHYSIOLOGICAL, PSYCHOSOCIAL, CULTURAL/SPIRITUAL VALUES, AND DEVELOPMENTAL) AFFECTING HEALTH AND WELLNESS and to

DISCERN REFLECTIVELY ON THE INTERACTIVE PROCESS BETWEEN SELF AND AN INDIVIDUAL DURING HEALTH ASSESSMENT

 

COURSE OUTCOMES

THIS ASSIGNMENT ENABLES THE STUDENT TO MEET THE FOLLOWING COURSE OUTCOMES:

CO#2. Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of nursing process while obtaining a physical assessment. (PO 4, 8)

CO#3. Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)

CO#4. Utilize effective communication when performing a health assessment. (PO 3)

CO#6. Identify teaching/learning needs from the health history of an individual. (PO 2, 5)

 

Nurses are required to ask many questions of patients, learning to do so thoroughly and with empathy and without judgment are important.  Do not simply “fill in the spaces” but instead investigate, ask follow up questions as appropriate (symptom analysis) and do your best to put all the “pieces of the assessment together.” This allows you to obtain a complete overall impression of the person’s current health status and actual and potential health issues (use D’Amico chapter 10 as a resource and guide).

 

 Biographical Data for the NR 302 – Health Assessment

 

Initials: B.P        125/80 Address: 567 Battle Creek road Jonesboro, GA 30236

Gender:  Male

Age: 41 years     Birthplace:  California

Ethnicity: Black American

Stated Height: 5.5ft.                 Stated Weight: 245pounds                Calculated BMI: 26.3

Relationship Status: Married

Children: 3                    Gender:  Male & Female          Ages: 18yrs, 22 – Male & 20yrs- female

Religious Preference: Christianity

What are the Religious practices?  Anglican

Primary language spoken: English

Living Situation:  Client lives with his family in a two-bedroom house; they have pets and flowers in their room.

Occupational History: the client works as an accountant in a bank.

Educational level including last grade completed: Client had a degree in accounting and finance.

Source (who is providing the information) & reliability (is source consistent with answers):

The he information in this assessment was obtained from the client personally.  The responses were consistent during the interview and therefore, the information obtained during the interview was valid.

Present Health Issue:

  • Reason for seeking care (remember always subjective and always in quotes)

Client states “I experience headache regularly and jaundice”.

 

Past Medical History in the NR 302 – Health Assessment

  1. Childhood and other illnesses (age, illness, any complications/residual issues. Ask about measles, mumps, rubella, chicken pox, pertussis, strep throat, mononucleosis, rheumatic fever, scarlet fever, poliomyelitis)

The client had a history of anemia and stomatocytosis.

Accidents or Injuries (age, injury, severity, treatment, residual problems – auto accidents, fractures, head injuries, loss of consciousness, burns)

The Client had no history of accident or injuries in the past.

  1. Hospitalizations & surgeries (year, cause, treatment, length of hospitalization, results)

Client stated that he has been hospitalized in few occasions following the anemia attack and liver problems.  He normally stays one week depending on the condition of each attack. However, he specified that proper and regular medical intervention helps in management of the condition and reduces the frequency of visiting hospital.

Immunizations: childhood immunizations and other immunizations, hepB, HPV, flu, pneumococcal, shingles, last Tb test? Provide estimated dates/reactions

The client went through all the childhood immunizations as outlined in the immunization schedule and all has been completed.  His record indicates that he takes pneumococcal vaccination and Hepataitis virus vaccinations.  . The record shows that the client also took pneumococcal vaccine on July 3, 2014 due to his chronic health condition and the vaccine is still valid until after 5 years.  There was an indication on his records that he was assessed of shingles and other skin diseases on his last visit in the hospital. No rash or discoloration noted.  TB test was done and no positive reaction was noted.

  1. Allergies (medication – list reaction/side effect, include foods and seasonal/environmental allergies, latex allergy and any treatment for same)

The client has no history of allergy.

  1. Current Medications including supplements: prescription and over the counter (OTC). Include name of medication, dose, schedule, what for, and how long person has been taking:

The client uses folic acid supplement to manage the anemia. In some occasions, the client undergoes transfusion because of the greater turnover of the cells, which consumes the vitamin. The client uses Ibuprofen to manage the pain during acute anemic condition, which causes a lot of pain and headache to the patient.

OB/GYN history or reproductive status: Live Births  N/A  Ab/Incomplete pregnancies N/A

  1. Course of pregnancies/complications:  N/A

 

Family History (Genogram/Pedigree of person, siblings, parents, grandparents, aunts, uncles, children, grandchildren)

Make a list of all family members (females represented by circle, males represented by square, put brackets if through adoption, draw diagonal line through circle/square if deceased and indicate reason for death and age at time of death, below circle/square put relationship (brother, aunt, etc.) and any health issues for that person.  Specifically ask about family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease and tuberculosis. Attempt to include three generations. If your patient is adopted and does not have family history information, construct a genogram on a person who does have knowledge of family history

See page 172 in D’Amico textbook for a guide to constructing a genogram. You may also download a template from the internet.

Note: The drawing of the client’s genogram is attached separately; PLEASE SEE THE ATTACHED COPY on the drop box.

 From the genogram, the father of the client dies at the age of 56, while his mother is alive. His grandmothers is alive however, the grandfather died and had history of anemia.  The client has three children two sons and one daughter who is also anemic and presents with stomatocytosis. The client might have inherited the condition from the grandmother. The client’s grandfather was a smoker and also used to take alcohol.

Health Related Behaviors & Social History

  1. Nutrition/Diet: (type of diet: 24 hour recall, trying to gain/lose weight, vitamin supplementation, alcohol intake (type) caffeinated beverages

I asked the client to verbally recall all food, beverages, and nutritional supplements or products he has consumed in a set 24-hours period.  He recalled that he ate sliced toast bread, a plate of macaroni & cheese with a cup of coffee in the afternoon, rice with fries with a cup of apple juice at dinner and ate snacks in between the hours of mid-night till the next day. Client takes alcohol drinks and denies smoking but acknowledges that he takes up to 10 cups of water daily.

  1. Exercise/Activity: What is a typical day of activity? Independent or needs assistance with activities of daily living (ADL’s)?

The client has a regular exercise almost every day. Some of the exercise activities include running, playing football, jogging, walking.

Interpersonal Relationships:  (current relationships, issues of domestic/intimate partner violence, does person feel safe in current relationship). Describe own role in family. How much time is spent alone daily?

During the interview, the client responded appropriately and freely to all questions asked. The client demonstrated good interpersonal relationship with his family members. He was married with three kids who were still in school, the wife is a live, and they live together as a family. Currently the client lives alone in his house and there is no history of domestic violence.  He goes out daily for work, except when he feels sick, and spends less time at home.

  1. Safety: (include use of seat belts, helmets if bike or motorcycle, smoke alarms in home – number and when batteries changed, firearms in home)

The client observes safety measures such as putting on safety belts while driving. He is very cautious to get into activities that will cause injury to his body, which may result to blood loss.

  1. Occupational hazards & Environmental exposure risks: (exposure to noise, pesticides, toxic materials, chemicals, dust, safety issues related to equipment)

Does job involve repetitive motion? 

The client’s job does not involve repetitive motion and there are also limited risks associated with the occupation. The main risk involved in the occupation is the risk of robbery and gang star attack.

  1. Substance use (history and current use; Illicit drugs: cannabis, cocaine, heroin, amphetamines, hallucinogens, pain medications, other). Tobacco use. Has person ever attempted to quit smoking?

The client consumes alcohol though at a regulated rate. He said he takes alcohol thrice a week.

  1. Sleep: (quality/quantity, sleep pattern, is medication taken to enhance sleep?)

The Client has a regular sleeping pattern and does not require medication to enhance sleeping except for when he is sick.

Travel pattern: (commute, increased risk due to heavy traffic area, travel to foreign countries)

The client do not travels on  a regular basis, he has not been to a foreign country, though during the interview, he said that he drives himself to his workshop, shopping mall, doctor’s visit, and to the church , but do not drive immediately after taking  his medication because he always feel dizzy after taking each medication.

  1. Psychosocial and spiritual well-being and self-concept.

The client is a who goes to church on every Sunday. In addition, he is a church leader and interacts with many people in his life. He is outgoing and social.

Review of Systems

Remember this is not a physical assessment; you are asking questions to the person regarding each system for signs/symptoms. Include the OLDCART & ICE acronym to guide the gathering of information and analysis of the symptoms. See page 164 in D’Amico

 

Directions: Ask your patient about every symptom. Document “patient denies” if your patient does not experience the symptom and do not check the box. If your pt. says “yes” mark the box and analyze the symptom with OLD CART ICE & record the subjective data under additional information. Please refer to a medical dictionary to learn the meaning of terms that you may not know.

ANSWER EVERY HEALTH PROMOTION QUESTION.

What is the general overall health? (In patient’s own words)

The client state “I am not feeling too good now, I have headache and some signs of jaundices. I also feel tired and weak.’

Present weight in pounds:245.       any/gain/loss?

The client had not realized weight loss or gain within the last 3 months.

þmalaise

  • fever
  • chills
  • night sweats

Additional information:

 The client feels malaise when the hematocrit level is too low. The test indicate reduced hematocrit and reticulocyte counts.

Skin

  • eczema
  • psoriasis
  • hives
  • change in mole
  • excessive dryness
  • excessive moisture
  • pruritus
  • excessive bruising

How does patient care for their skin & hair?

The client washes his hair and skin on daily basis.

Additional information:

Hair

  recent loss

  • change in texture
  • change in nails

Amount of sun exposure per day? At least 3 hours per day

How does patient protect self from sun excess for hair/skin? The patient uses protective clothing to protect himself from direct sunlight.

Additional information:

Head

þfrequent headaches

  • head injury
  • dizziness (vertigo)

Additional information:  Clients experiencing dizziness and headache because of the reduced oxygen supply in the body.

Eyes

  • changes with vision
  • does patient wear glasses or contacts
  • has patient had Lasik surgery
  • eye pain
  • double vision
  • watering/discharge or redness
  • glaucoma
  • cataracts

When was patient’s last vision check?

The patient has a normal visual acuity and undergoes checkup after two years.

Additional information:

Ears

  • earaches
  • infections
  • tinnitus
  • hearing loss
  • use of hearing aides

How does patient clean their ears?

Additional information:

Nose/Sinuses

¨Discharge

  • frequent colds
  • sinus pain

¨Nasal obstruction

  • nosebleeds
  • change in sense of smell

Additional information:

Mouth/Throat

  • mouth pain
  • sore throats
  • bleeding gums
  • toothaches
  • lesions in mouth or on tongue
  • dysphagia,
  • hoarseness
  • altered taste

What is patient’s usual pattern of dental care and when was last dental visit?

The client ensures regular cleaning of the teeth as dental care measure and has no experience of toothache.

Additional information:

Neck

  • pain,
  • limited movement

Additional information:

Breast/Chest (for male patients also)

¨Pain

  • lumps in breast
  • lumps in axillary region

Breast self- exam pattern?  Client performs self – breast examination before or after taking shower, by standing in front of the mirror and palpate accordingly.

When was patient’s last mammogram or clinical breast examination?      N/A 

Respiratory system

  • pain with breathing
  • shortness of breath

¨Cough

How much activity leads to shortness of breath?

The reduced red blood cell in the body causes shortness of breath. Red blood cells are responsible for the transportation of oxygen to all parts of the body.

Additional information: 

Cardiovascular

¨chest pain

  • palpitations

Additional information:

The client has a normal cardiovascular function; however, he experiences a stabbing pain on his chest during the asthmatic attack.

Peripheral Vascular

  • coldness
  • numbness/tingling

þSwelling of legs

þDiscoloration of hands or feet

þPain in calf when walking

Additional information:

Discoloration of the hands and feet, pain when walking and the swelling of the legs results from insufficient oxygen supply in the body.

Gastrointestinal

  • food intolerance

¨heartburn or indigestion

  • nausea or vomiting
  • recent changes in stool
  • constipation

What is the patient’s frequency & quality of bowel movements?

Client bowel movement is normal.

Additional information:

Urinary system

  • Frequency
  • dysuria

How often does the patient void & what is the color of the patient’s urine?

The patient undergoes normal urination process; urine color is clear, no foul odor noted, and no pain with regular urination.

Additional information:

Male Genitourinary system

  • Penile pain
  • testicular pain
  • penile discharge or lesions

Testicular self- exam pattern?

The client performs testicular self-exam once a week during shower. He has a normal functioning genitourinary system, however, because of the advance age; he has a regular screening for prostate cancer.

Female Genitourinary system & Reproduction

  • age at menarche
  • last menstrual period
  • cycle/duration/pain associated with menses
  • vaginal itching or discharge

Age at menopause

 When was patient’s last PAP screening? N/A    

Sexual Health

  • Is patient sexually active
  • Any pain with sexual activity

What is the form of contraception and/or STI prevention used? 

The client is sexually active. He practice safe sex, he uses condom during sex and is faithful to his partner.  No pain noted during sexual activity.

Aware of contact with partner who is STI positive?

Both the client and the wife are healthy and there is no positive case of STI.

Musculoskeletal system

  • pain/stiffness
  • swelling in joints
  • cramping
  • Back pain

Additional information:

The client has a normal physiological function of the musculoskeletal system with normal anatomical structures.  No sign of arthritis or bone inflammation.

Neurologic system

  • seizure activity
  • “blackouts”
  • coordination problems
  • Nervousness
  • mood changes
  • Depression

Additional information:

Hematologic system

  • bleeding tendencies
  • excessive bruising

þhistory of blood transfusions

Additional information:

The client has a regular transfusion history, which is conducted when the blood count level is too low. This results from the dysfunction in the hematological system.

Endocrine system

¨Intolerance to heat/cold

  • change in skin texture
  • excessive sweating
  • abnormal hair distribution

Additional information:

Reflection and Application through Critical Thinking

How did you feel about the interview and interaction? Discuss what you have learned about therapeutic communication: what barriers to communication did you experience? Were there unanticipated challenges to the interview? Was there information you wish you obtained? How would you alter the interview next time?

The interaction during the interview was healthy and enjoyable. The client was ready to share information and respond to questions asked. During the interview, the client got the chance to inquire about some of the issues affecting his life such as reproductive health apart from the content covered in the assessment. I used the open-ended questions in order to gather enough information relevant for the assessment. I employed communication skills during the interview and this helped in the achievement of the required results during the session.

The main challenge during the interview includes difficulty in the management of time since the client introduced a lot of issues to be discussed. The other challenge was that it was difficult asking some sensitive questions such as are you sexually active to the patient; I am a bit shy when it comes to that. It was important to prepare the client before the interview session so that the client could gain courage to participate the assessment. The client could not remember exactly some information and therefore, he could guess. I tried my best to ensure that time management was observed despite a few challenges here and there. The discussion during the assessment was conducted in turns whereby each one of us was given a chance to express their ideas. Balance in the communication was necessary for proper assessment process.

 If you did a physical assessment on this patient, which body system would be your top priority, and why?

I would focus in assessing the hematological system. This will mainly involve the assessment of various factors that causes anemia and how to differentiate between chronic and acute anemia. In the assessment, it would be important to analyze whether the bone marrow disorder was responsible for the anemic condition in the patient. The patient also presented with jaundice, the assessment will help in the establishment of the relationship between red blood cell depletion and jaundice.

Make a list of three health/wellness issues you consider to be priorities for this individual (consider age, psychosocial, cultural and lifespan considerations).  Issues may include: immunizations, safety, nutrition, exercise, substance abuse, smoking cessation etc.

The three health issues that are appropriate to the client include:

  • Immunization
  • Substance abuse.
  • Nutrition

Discuss how these issues relate to each other or affect each other.

The three issues are very important in addressing the condition of the client. The patient need to take a balanced diet that will ensure the replacement of the red blood cells in the body. On the other hand, nutrition will promote the development of the body tissues and the formation balance of ions in the body since stomatocytosis is associated with an imbalance in the body ions. The client should stop consuming alcohol since alcohol affects the liver function. Liver is responsible for detoxification and formation of globulins in the body. Proper liver functioning helps in the management of jaundice. The client should also be immunized in order to boost the body’s immune system. Blood disorders normally affects the body’s immune system.

 

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