Comprehensive Health Assessment and Documentation - Term Paper Example

Comprehensive Health Assessment and Documentation Introduction Comprehensive assessment and documentation is a vital part of the nursing care process. It serves as the foundation of nursing care and it serves as a guide for the planning of care for the patient. This paper shall present the assessment conducted on an adult female. The patient is 29 years old, married, with a 10 month old baby, and working as a history professor in a university. She was admitted with right lower quadrant pain and after a series of diagnostic tests she was diagnosed with an acute appendicitis. She was scheduled for an appendectomy 20 hours after admission. The comprehensive health assessment shall be conducted and later presented in this paper for the patient’s Primary Health Care provider. Such comprehensive history shall later be used to adapt a plan of care for the client and to assess the comprehensive assessment skills of this student. Assessment of Psychosocial and Spiritual Status Level of consciousness The patient’s level of consciousness is good. She is awake and alert. She understands the questions and also responds appropriately and reasonably quickly to the questions asked. Posture and Motor Behaviour The patient is lying in bed. She is in a side-lying position with her knees bent. She is also clutching her lower abdomen while in this position. She is not relaxed because of the pain she is experiencing. All her movements seem to be voluntary and under her control. Dress, Grooming, and Personal Hygiene The patient’s clothes are clean and properly fastened. They are appropriate for her age and social group. She is well-groomed; and she has clean nails, hands, teeth, skin, and hair. Both sides of her body appear to be properly groomed and well-cared for. Facial Expression She grimaces often from the pain she is experiencing. She also looks worried and anxious about her upcoming surgery. She often guards her expression when her family members are around. The changes in her expression match the topics under discussion. She manifests expressions of anxiety when the attending physician told her that she had an acute appendicitis, and again when she was told that she had to have an appendectomy. Manner, Affect, and Relationship to Persons and Things The patient’s affect varies accordingly based on the topics under discussion. They are also appropriate based on the topic being discussed. She is open and approachable and reacts appropriately to other people and to the surroundings. She does not appear to see or hear things which are not there. Speech and Language She is relatively silent; but she spontaneously responds to questions being asked of her. The speed of her speech varies. She speaks fast when she is in pain and slows down when the pain subsides. She speaks softly and is sometimes inarticulate when she is experiencing extreme pain. When the pain subsides, she speaks clearly and distinctly. The flow, rate and melody of her speech seem to be normal. There are no hesitancies and gaps in the flow and rhythm of her words. There are also no circumlocutions or substitutions in the words she uses. Mood The patient is anxious and worried about her condition and the upcoming surgery. She feels that her condition may have been brought on by work stress and by her multiples responsibilities. She feels sad about her current situation because she feels like she is now being a burden to her family. She is also worried about her baby. Her friends and family express that the patient has always been a very responsible person. Generally, she is a happy person, but since she had her baby she got stressed with work and family commitments. Questions to assess depression were asked and the patient does not seem to be depressed; but she is worried and anxious about her situation. Spiritual Status (FICA Model – Faith, influence of beliefs, community, and address in care) Faith and beliefs The patient is a devout Methodist. She is religious and her spiritual beliefs help her cope with stress. Influence of beliefs Faith is a big influence in her life because it helps her decide momentous and overwhelming situations. Her beliefs do not influence the way she cares for herself. She believes that in keeping herself healthy, she will be able to avoid getting sick. She believes that prayer and faith is part of the process of getting well, but she does not solely rely on these beliefs to get well and to deal with her problems. Community She is also part of a religious community. She is a Sunday churchgoer and she participates in church activities. These activities support her emotionally because being in the community helps relieve her stress. Address in care She puts great value on her friends and family; she makes it a point to take the weekends off with her family, and to go on weekly lunch dates with her girl friends. She is open in having me, her health care provider participate in the spiritual aspects of her care. She believes that I will understand and respect her spiritual needs. Assessment of Cognitive and Perceptual Status Thoughts and Perceptions The patient’s logic, relevance, and organization of thoughts are coherent. She reveals these thought processes throughout the interview. Her speech progresses logically toward a goal or an overall point. Throughout the interview, she did not manifest derailment, flight of ideas, neologisms, incoherence, blocking, confabulation, perseveration, echolalia, and clanging in her thought processes. Her thought content does not contain any abnormalities. She does not show any compulsions, obsessions, phobias, anxieties, feelings of unreality, feelings of depersonalization, and delusions. The patient also does not have any hallucination and illusions. She does not hear or see anything that is not there. She also has proper insight on her condition. She knows why she was brought to the hospital and that she needs proper medical attention and treatment for her affliction. She is also not in denial about her condition. She also has good judgement about her family situation, her resources, and her job. She knows she has to delegate family and work responsibilities for the meantime. She is also aware that she has to let her family members help in caring for her baby and for themselves. Cognitive Functions The patient is not disoriented. She is aware of the time, the date, where she is, and who her family members are. Her attention is good and focused. She tested well on the digit span, series of 7s, and spelling backward tests. She has a good recall for birthdays, anniversaries, her social security number, the schools she attended, the jobs she held, and other past historical events. Her recent memory is also intact. The detail she narrates about her recent activities prior to and during admission coincides with details narrated by her family members and by hospital personnel. Her ability to learn new things is also good. She can easily repeat and recall words narrated to her. The patient’s higher cognitive functions, such as information and vocabulary, are intact. She has a good grasp of information, the complexity of ideas expressed, and the vocabulary used. She was able to recite the name of the president and the governor, as well as the names of the last 6 presidents, and the names of large cities in the country. The patient can do simple arithmetical calculations well. She can add, subtract, divide, and multiply well. She can also solve practical questions involving arithmetical calculations. Her abstract thinking is good. She can understand implications and meanings in proverbs and sayings. She can also analyse similarities well. Finally, her constructional ability is also intact. She can copy accurately the figures of increasing complexity as shown to her during the assessment. Assessment of nutritional/metabolic status Body Mass Index The patient’s body mass index is 24. She is within the normal BMI range. Her weight is also appropriate for her height. Her waist circumference is 28, which is also appropriate for her. Her body fat is distributed evenly throughout her body. Based on this general assessment of her weight and height, she is not obese, nor is she overweight. Nutrition Her food intake consists of the six major food groups. She does her best to eat three meals a day on time; however, due to her busy schedule, she sometimes skips meals. Her food servings are also based on the current health recommendations. She has not experienced any drastic and unexplained changes in weight. Five months after delivering her baby, she dropped the weight she gained during her pregnancy. She engaged in exercise and observed a healthy diet during and after her pregnancy, and this allowed her to lose weight. The weight she gained during her pregnancy was within the expected weight gain. Such weight gain was monitored by her obstetrician. At no point during her pregnancy did she gain or lose too much weight. She also has not experience any fatigue and weakness recently or in the past. The weakness she mostly felt were right after delivering her baby. Since then, she has not experienced any weakness or fatigue. Based on her 24-hour diet recall, she consumed 7 portions of grains, cereals, and bread group. She also consumed 2 portions of fruit groups; and 5 portions of vegetable groups. She consumed 4 portions of meat groups. For dairy groups, she consumed 2 portions during the past 24 hours. She had a portion of sweets shared with her husband; and she has not had a soft drink for quite a while now. She has had 2 portions of wine during the last 24 hours. Based on the nutritional screening checklist, she scored 2, which puts her at low risk. This means that she has access to healthy meals and there are no circumstances surrounding her consumption habits which endanger her health. She does not suffer from any eating disorders like anorexia or bulimia. She also does not appear to suffer from any vitamin or mineral deficiency or excess. Exercise She exercises in the morning just after waking up and before going to work. She runs on her treadmill for 30 minutes every day. She also plays tennis with her husband during the weekends. She has not experienced any increase in blood pressure at all. Her yearly physical examinations reveal that her blood pressure is within the normal range. During her pregnancy, her blood pressure also stayed within the normal range. She reads food labels and checks the nutritional contents of the food she purchases and eats. Assessment of Sexuality/Reproductive status Menarche/Menstruation/Menopause The patient had her first period at the age of 14. She recalls that her last period started about 20 days prior to her admission. Her periods come regularly because she is on the pill. They last for 5 days, and the flow is moderate to heavy. The colour is dark red. She normally uses about 7 pads a day during the first 2 days of her period, and then about 5 pads on the last three days of her period. She does not experience any bleeding in between periods; nor does she experience any bleeding after intercourse or after douching. She usually experiences dysmenorrhea and discomfort during the first 2 days of her period. It is usually a dull throbbing pain and occurs intermittently. Pregnancy As was previously mentioned, she gave birth about 10 months prior to admission. She fell pregnant when she was 18 years old, but had an abortion after. The abortion was induced. She did not experience any complications from said abortion. She also has not had any difficulties during her recent pregnancy. She is now on birth control pills and such pills seem to agree well with her body. She is not experiencing any side-effects or adverse reactions to the pills. She does not, nor has she ever, experienced any vaginal discharges. She and her husband are also not experiencing any sexual problems. She says that they have sex often and she is satisfied with their sex life. She also does not experience pain during intercourse. Her pap smear came back negative for malignancies or abnormal cell growth. Internal Examination The internal examination of her vagina revealed no bulging in the vaginal walls. Inspection with the vaginal speculum did not reveal any retroversion of the uterus. There were no discharges noticed during the inspection. There was also no inflammation, ulcers, or masses noticed during the inspection. There was no pain experienced by the patient upon examination and palpation of her cervix. Palpation of her uterus also reveals no masses, no enlargement, no pain, and no tenderness. The palpation of her ovaries also reveals no masses, tenderness or pain. There is also full strength in her pelvic muscle. The patient also had no hernias. Reference Bickley, L & Szilagyi, P 2007, Bates’ guide to physical examination and history taking, 9th edn, Philadelphia: J B Lippincott, Williams & Wilkins Young, C. & Koopsen, C., 2005, Spirituality, health, and healing, New Jersey: SLACK Incorporated Read More