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• NR306 Health Assessment
• Purpose
• Preparing the assignment

9

Health Assessment Assignment Presentation

NR 306 Health Assessment Assignment

1. Demographic Data

Rich (not his real name) is a 60-year old African American husband and father of four. He lives with his extended family in Bozeman Montana, where he has established a small farm where he breeds horses. He states that this is not only his current job but a hobby too. Rich is a retired Lumberjack who spent most of his younger life in the forests of British Columbia felling trees and supervising his colleagues. HE worked in the field for 30 years, after which he quit to take care of his ailing wife, who was suffering from cervical cancer. He would climb many hills felling trees while carrying a 40-pound chainsaw in 10-hour day shifts. Later on, he was promoted to a supervisor, tasked with monitoring and overseeing the work of his colleagues. After his wife’s recovery, they both decided to retire on a rural farm and established a business out of their passion. Rich. His wife was a housewife, taking care of the family and volunteering at a local children’s home on regular basis. He works out three times a week and is very particular about what he eats. He does not have any chronic condition but had hip replacement surgery two years ago. Rich does not smoke but likes to enjoy a cold beer with his friends on game nights

2. Review of Systems

The patient indicated that he has no known allergies. No physical abnormalities were observed on his skin, and he indicated no known issues. He denied experiencing any muscle weakness, fever or chill. The patient has presbyopia and has to wear glasses for correction of both short-sightedness and long-sightedness. He underwent Lasik surgery when he was 40, which corrected his myopia until he turned 55. He can read well and don’t experience any eye pains during the examination. Rich does not experience any shortness of breath or chest pain that would indicate a respiratory issue. Neither was an abnormality detected in his cardiovascular, musculoskeletal, and neurological or gastrointestinal systems. However, he indicates his struggles with an ingrown toenail which is preventing him from properly wearing a shoe. Rich is proud of his current health status and associates it with regular exercising at his age and having a proper diet.

3. Past/Family/Perception of Medical History

Rich comes from a family with a history of diabetes, but he is not affected. His wife is hypertensive but they manage the condition through diet and alternative medicine such as herbs and nutritional supplements. His mother was a chain smoker who succumbed to the complications of liver cirrhosis and diabetes. She passed away at the age of 53 after being in a coma for two weeks. Rich also has a sister, who is currently battling cystic fibrosis. She is recovering from a double lung transplant she underwent three months ago. She considers Rich to be the healthiest member of the family as he is the only one who is alive and free from a chronic condition. Though healthy, Rich is concerned about a possible genetic predisposition to prostate cancer because his father suffered from the condition before he passed away in a traffic collision when he was quite young. He states that he does not trust oncologists as they can withhold some information when the health status of an individual is bad.

4. Reason for Care/Present Illness

Rich visited his primary health care provider for a scheduled annual review for health maintenance. He has this kind of consultation annually and hit has enabled him to remain in good health for some time now. Additionally, as mentioned above, Rich had an ingrown toenail which needed to be addressed. An ingrown toenail is a recessed nail hat curves inwards on the sides, thereby growing into the foe tissues. This becomes very painful, making him unable to wear a shoe or even walk properly. At his advanced age, he is at a risk of arthritis, prostate cancer and other chronic conditions as the risk increases with age. Rich is a pro-health individual, planning and healthily living his life to avoid falling sick. His inflamed toenail is making it difficult for him to do this effectively. He cannot engage in exercise or other routine physical activity. For this patient, the developmental consideration sate of Erickson’s Stages of Development is generativity vs. stagnation. His age frame corresponds with ages 40-65, and his actual age fits in this category. He is also quite optimistic but very cautious over health matters.

5. Cultural/Psychosocial Considerations & Present Resources

Rich is a strong Catholic; a very spiritual man with ideations of an afterlife and divine oversight. His African American values of family unity allow him to have at least one meal with his extended family and give him a closely-knit family. He often cooks for the family healthy meals and rarely eats at restaurants. His typical food is fish, green vegetables, root tubers such as yams, nuts and some ingredients which he buys either from the Chinese town or the African market. He also mentioned his love for religions, showing vivid detail in most of the religions worldwide which he studies. Rich is a philanthropist, helping many people around his community especially in matters of health. He organizes fundraisers for the local Cystic Fibrosis organization. He does not have any strong political views and neither does he vote because he claims that the political system can run without him. The patient’s extended family consists of his wife and his son, as his daughters have been married off, the family of his son, his sister and their family and three adopted children who live with him. He considers them to be his primary responsibility, and “the reason why I have to remain healthy at all cost.”

6. Physical Exam

Upon inspection of systems beginning Rich’s appearance was consistent with his actual age. He expresses his discomfort with his toenail which he fears could develop into cancer if left untreated. He was experiencing a lot of pain when walking, which he rated at 6 out of 10. The pain was localized to the toe but when he takes a step, it radiates towards the rest of the foot, making him feel like falling. At his age, any fall could be potentially serious especially considering his hip surgery a few years earlier. The patient was cognitively well responsive and showed no sights of distress during the conversation.

As a black man, his skin colour was healthy and consistent with his ethnicity. He had no observable lesions, wounds or lacerations that deserved attention. The nail colour was consistent with the rest of his body as well, with no noticeable abnormalities such as clubbing, deformation or discolouration. As indicated, the big toe on his right foot was a little inflamed on the side. It was quite painful to couch and its presentation was consistent with an ingrown toenail. The patient’s eyes had a normal presentation with pink conjunctiva, white sclera and responsive pupil. His eyes were well rounded and bilaterally equal. No abnormal secretions were observed. A similarly normal observation was made in his ears, with no swellings, piercings, secretions or inflammation. There were no deformities on the internal nose structures either. The mouse and throat were well most and healthy-looking. The structures were symmetrical and well functional.

The patient’s respiratory system’s assessment revealed clear lungs and no history of asthma, except for occasional influenza which gets him at least a couple of times annually. The normal curvature of his spine indicated no scoliosis, kyphosis, or lordosis. Palpation and auscultation of the cardiovascular system showed no abnormalities. Typical heart sounds were observed in the aortic, pulmonic, Erb’s point, tricuspid, and mitral areas. The auscultation was conducted with both the bell and diaphragm. No VD was noted. No heart murmurs were observed, but S1 and S2 sounds were noted. Radial pulses were present, and the patient was rated a 3+His feet did not reveal any oedema and his cardiovascular system can be said to be normally functioning.

The gastrointestinal system of the patient showed no abdominal lesions or abnormal sounds. Auscultation of the four abdominal quadrants was conducted, and palpation showed no tenderness or distention. Overall, no abnormalities were observed. His last bowel movement was six hours before the assessment. His genitourinary system was normal in appearance and history as well. The patient had no pain when passing urine. The musculoskeletal system was well contoured and functional, with the shoulders, elbows, knees, wrist, hands and ankles under normal appearance. His right toe was a huge challenge and needed surgical intervention to resolve. Neurological assessment of the various cranial nerves was also conducted, revealing a normal presentation.

7. Needs Assessment

The primary nursing diagnosis that took the greatest priority was his impaired ability to walk due to the sharp pain in his left toe evidenced by an ingrown toenail. To ensure that the patient is independent enough to lead his normal life, it is essential to get the issue resolved promptly. The patient is diet cautious and exercises oriented which gives him a very healthy musculoskeletal system at his age. He expresses his concern that he could suffer from hereditary prostate cancer like his father did but seems to understand that his healthier lifestyle can help him to achieve a better health outcome. It is essential to teach him about the various early markers of prostate cancer which he could watch out for to ensure that he identifies it early. As a pro-health personnel, the patient is well informed about taking care of himself and his family. He is very healthy and if he continues to live his life so cautiously, he could live very long.

8. Reflection

This assignment was my first patient health assessment and it proved to be very insightful. I learnt a lot about health assessment, review of systems and various other key factors that should be considered when assessing the status of a patient. I feel that he is an essential skill in nursing, which I will be applying extensively in my professional endeavours. To collect all this information, communication skills are essential for one to properly approach the patient and appropriately ask the proper questions. This interview was scheduled in a way that made the questions to be more of an interaction, where information was exchanged and the various observations made. I had to make the patient feel and stay comfortable through the session for him to share as much as needed and experience the professionalism with which his case was being handled. As Ross (2017), illustrates, the patient has to be made to make to feel that he was in control of the whole interview and assessment process. I learnt the value of patient cooperation, debut and establishment of a free, friendly and open communication channel where anything can be shared.

The greatest challenge when conducting this assessment was gathering enough confidence to assess to feel professional in light of my age and his health care priorities. My fears were not substantial because everything was done in the presence of a supervisor who guided and sought clarification. In future, when conducting a health assessment, it would help to be more confident and respect the nurse’s competence (Toney-Butler, & Unison-Pace, 2018). I feel like I undermined myself, which was not good for my overall performance. I found the whole assessment to be confusing as there are many systems and structures to be assessed.

In future, it would be helpful to be more confident when conducting the assessment and to trust me through the whole process. It would also help to observe several more assessments being conducted so that I can identify better ways to connect with the patient, save time and address everything rightfully. With time, I am sure that I will get much better at conducting health assessments.

References

Ross, A. Bevans, M. (2017).Nurses and Health-Promoting Behaviors: Knowledge May Not Translate Into Self-Care. . PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5536335/

Toney-Butler, T. J., & Unison-Pace, W. J. (2018). Nursing admission assessment and examination. https://europepmc.org/article/nbk/nbk493211