Self-assessment of comprehensive health assessment Essay Example

  • Category:
    Nursing
  • Document type:
    Assignment
  • Level:
    High School
  • Page:
    3
  • Words:
    1747

TOPIC: SELF- ASSESSMENT OF COMPREHENSIVE HEALTH ASSESSMENT

By student’s Name:

Code+ Course:

Instructor’s Name:

University Name:

City, State:

Date of submission:

Patient history & physical examination assessment proforma

Criteria

Independent & Excellence

Infrequency assisted & good

Assisted & satisfactory

Frequency assisted and borderline

Dependent & unsatisfactory

History of presenting complaint

Description of symptoms

Effects on patient’s life

Patient understanding of the problem

Welcome to our clinic. I would like to note your age for the purposes of record keeping.

Any present illness. Head, nose, ears or eyes.

Any related problem to pertaining to eyes, nose, ears or the head

Have you been diagnosed with any childhood illnesses? Which may include; measles or chickenpox.

Head: inspect the face, scalp, hair and skull.

History of any injury associated to the head.

Any adult illnesses; medical; pyelonephritis, diagnosed with fever in 1982 and right flank pain, ampicillin was used in treatment; several days later generalized rash coupled by itching developed. Reports normality of kidney x-rays; infection; no recurrence.

Eyes: examine visual acuity. Note the eyes’ alignment and position.

Eyes; used glasses since 2008. Last check 2 yrs ago.

Any surgical history. A t age 6, Tonsillectomy, age 13; appendectomy. Laceration sutures in 1991, having stepped on glass. Lack of sex interest.

Ears: check the drums, auricles and the canals.

Ears: no related problem to hearing

Any immunization; polio vaccine (oral), not certain on the year. 1991 tetanus shots (x2), 1 year later (booster); 2000, flu vaccine

Nose: inspect the nasal mucosa, turbinate and the septum.

Nose; frequent mild cold.

Past Medical History.

Family history

Allergies

Do you have any family history of tuberculosis, cancer, diabetes, anemia or epilepsy? No

Any allergy related to drugs, mold, wheat or spring

Father died at the age of 70 of stroke; persistent headaches; varicose veins

Drug allergies; allergic to some drugs

Mother died at the age of 45 in car accident.

Spring allergies. No such allergies

Husband died at the age of 47 due to cardiac arrest.

Wheat allergies; allergic to wheat.

One sister, 43, had hypertension. Diagnosed and treated.

Mold allergies. No such allergies.

Psychological history.

Nutrition

Alcohol/drugs

Physical exercise

Emotional/mental health.

Occupational history

Do you have any problem with smoking? No

What is your current body weight?

Do you have any problem with drinking? Yes.

How often do you engage in physical exercise?

Have you ever suffered any mental illnesses in your life time?

What is your current occupation?

Well, do you smoke? Yes

Have there been recent changes to your body weight?

Well, have you ever consumed alcohol before? Yes

What kind of activities do you involve yourself in while doing physical exercise?

Do you normally experience persistent headaches?

How do you like your current occupation?

What type of tobacco do you smoke?

How many meals do you take per day? Do you prepare food for yourself?

Why did you quit drinking? Once diagnosed with liver cirrhosis and treated.

How do you like jogging?

Are you regularly depressed or stressed?

What are some of your important life experiences?

How long have you smoked cigarettes?

How often do you consume a diet containing vitamins and minerals?

When did you quit drinking and for how long had you taken alcohol?

When did you start jogging?

Do you have problem with forgetting?

Would you mind giving me a brief history of your job?

How many cigarettes do you smoke per day?

Do you always take a balanced diet?

How have your health improved after you quit drinking?

What time do you normally jog and the duration of jogging?

How long can you take to do simple calculations?

What are some of your activities of daily living?

Systems review

How are your ears and hearing?

How about your lungs and breathing?

How is your digestion?

Do you have any trouble with your heart?

How about your eyes and the vision?

Inspection

Vital signs, weight

Any notable changes in your current body weight?

Have you lost weight or gained so far?

By how much pounds or kilograms have your weight increased or decreased?

Have you experienced any problems with your appetite?

How many meals do you take perday?

Physical examination:

General/Skin

Neurological

Respiratory

Cardiovascular

Gastrointestinal

Genital/Urinary

Musculoskeletal

Others (Neurologic)

Observe the face skin and some of its characteristics.

Assessment on the patient’s mood, abnormal perceptions and the thought content

Note the colour of the sputum and the quantity.

Check the blood pressure.

Assess any trouble while swallowing.

Check the urination frequency.

Assess on the joint pains or muscle pains.

Access on mood changes.

Any lesions should be identified.

Check the corneal reflexes, sense of smell, sternomastoid muscles and the gag reflex

Check any sign of hemoptysis or dsypnea.

Any sign of rheumatic fever.

Examine the bowel movements.

Assess whether there is any pain or burning during urination.

Any sign of stiffness, arthritis, backache or gout.

Changes in orientation.

Inspect and palpate nails and hair.

Examine the muscle bulk, muscle group strength and the tone.

Note any sign of wheezing.

Assess whether the client has chest pain or any sign of discomfort.

Assess any sign of nausea, heartburn or appetite loss.

Note whether the client has flank or the kidney pain

Any swelling, tenderness or limitation of motion or activity.

Loss of sensation.

Study the hands of the patient.

Check the temperature, pain, light touch, discrimination and the vibration.

Check any sign of pleurisy.

Assess whether the client has heart trouble.

Check any sign of rectal bleeding or trouble on the gall bladder.

Assess on the urinary stream force.

Assess on joint pains with features which may include anorexia or fever.

Blackouts, paralysis or headache.

Continue with skin assessment as you examine the rest of the body regions.

Check reflexes that’s the biceps, brachioradialis and the Babinski reflex.

Carry out a chest x-ray.

Review of results on past electro-cardiograms.

Assess the color and the size of stool.

Check on urinary infections and the kidney stones.

Assess on any trauma history.

Check on involuntary movements.

At the completion of examination.

Ensure comfort and safety

Document

relevant information

Diagnostic x-ray & test recommendation.

Patient should be seated when assessing vital signs.

Information on the client is provided on the report.

Assessment provided below.

Assessor’s comments: …………… Grade: ………………….

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Assessor’s signature: …………. Date: ………………….

Student’s comments.

Mrs. X is middle aged woman, short, a little bit overweight and responds well to questions. She is fairly tense, good posture, moist hands and good gesture. Her skin color is fine and lies flat with no anxiety.

Student’s signature: …………….. Date: …………………..

Student’s learning objectives.

  • Gain more knowledge on data assessment and collection which may include the data on temperature and pulse.

  • Sufficient auditory ability to assess as well as to monitor health care related needs which may include; alarms monitoring, verbal communication, emergency signals and the ausculatory sounds.

  • Attain necessary and sufficient visual ability for proper observation of a client/patient.

Report on the findings

Present Illness

Although Mrs. X seems alright, she has had persistent frontal headaches for the past three months. These include; bifrontal and throbbing which result too severe pain. Sometimes she experiences nausea and vomiting. Her headaches are stress related and average once per with duration of 3 to 5 hours. Her headaches are normally relieved by sleep or placing a dump tower on top of her forehead (Lorraine, 2005). The client complains on increased pressure at her place of work from her current boss.

Social history

She thinks her headaches are normal but she wants to be more certain as her father died of stroke. Her main concern is the interference the headaches have on her work. She takes three meals per day. Medications; Aspirin, 3 to 5 hours as required, ‘water pill’ for ankle related swelling (Rick & RN, 2004). Allergies; She is allergic to Amplicin. Tobacco.5 cigarretes daily since age 20.

Past history

Child Illnesses: Chicken pox and measles. Neither rheumatic nor scarlet fever (Marilynn & Mary, 2013).

Adult Illnesses, Medical; 1990 diagnosed with fever and the right flank pain; ampicillin was used for treatment though a few days later she had an itching generalized rash. Reports normal kidney x-ray; neither recurrence nor infection (Sue & Keith, 2005).

Surgical: Medical, age 10 tonsillectomy; age 12, appendectomy. Laceration sutures in 1990 having stepped on glass. Ob/Gyn: G3P3, with ordinary vaginal deliveries (Caroline & Mary, 2008).

Health maintenance: Immunizations. Polio vaccine (oral), year not certain; tetanus shots (x2),accompanied by booster a year later; year 2000; flu vaccine, no reaction. Screening tests: In 2002 last Pap smear, normal (Lois, 2011). Up to date no mammograms.

Review Systems

Head, Eyes, Ears, Nose, and Throat (HEENT): She has never had head injury. Eyes: she has been using reading glasses for 6 years, checked 9 months ago. No symptoms. Ears: hearing perfect. No tinnitus infection. Nose, sinuses: Frequent mild cold. No hay fever (Kristyn & Joanne, 2006). Throat: recently bleeding gums.

Respiratory: No wheezing, shortness of breath or cough. X-ray check-up year 2000; unremarkable (Linda &Lourie, 2012).

Cardiovascular: No related heart disease or high par tension. Blood pressure taken back in 2005. No chest pains, dyspnea or palpitations (Anne & Patricia, 2002). On no account did she have an electrocardiogram (ECG).

Gastrointestinal: No nausea, indigestion or vomiting (Violet, 1994). Good appetite. Movement of bowel occurs once per day, although especially when tense she has hard stools for about 2 to 3 days.

References

Anne Griffin Perry & Patricia Ann Potter,2002. Clinical nursing skills & techniques. St. Louis : Mosby.

Caroline Bunker Rosdahl & Mary T Kowalski, 2008.
Textbook of basic nursing. Philadelphia : Lippincott Williams & Wilkins.

Kristyn S Appleby & Joanne Tarver, 2006.
Medical records review. New York: Aspen Publishers.

Linda Seligman &Lourie W Reichenberg, 2012. Selecting effective treatments: a comprehensive, systematic guide to treating mental disorders. Hoboken, N.J : John Wiley & Sons.

Lois White,2011. Foundations of nursing: caring for the whole person. Albany, N.Y : Delmar/Thomson Learning.

Lorraine Loretz, 2005.
Primary care tools for clinicians: a compendium of forms, questionnaires, and rating scales for everyday practice.
St. Louis, Mo: Elsevier Mosby.

Marilynn E Doenges & Mary Frances Moorhouse , 2013. Application of nursing process and nursing diagnosis : an interactive text for diagnostic reasoning. Philadelphia: F.A. Davis.

Rick Daniels & RN,2004.
Nursing fundamentals : caring & clinical decision making. Australia; Clifton Park.NY : Delmar Learning.

Sue Cavanagh & Keith Chadwick, 2005. Health needs assessment: a practical guide. London: National Institute for Health and Clinical Excellence.

Violet H Barkauskas, 1994. Health & physical assessment. St. Louis, Missouri; Toronto: Mosby.