Health History and Physical Examination RUA
Chamberlain College of Nursing November 2014
In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.
Health History and Physical Examination
Health History
Under my care for the assessment was Felix Tshimanga, a 50-year old man who has been working in the hospital environment since his 20s. After living in New York for a little less than 10 years, he’s lived in Georgia for 10 years. The reason for
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Pulse rate is at 72. The blood pressure was 140 / 95,which is suggestive of high blood pressure and related to his medical history. No heart murmur was noted, and no other abnormalities were noted.
His gastrointestinal, musculoskeletal, and integumentary system were unremarkable.
Health Education
This section includes some recommendations, including but not limited to: * Healthy diet (balanced diet) by avoiding too much salt in food as salt tends to increase blood pressure. Avoid too much carbohydrates and starch to allow the body to breakdown excess fat in the body. Too much of bad cholesterol can be deposited in blood vessels, thus worsening the patient blood pressure (Baric, 1997). * Adopt some healthy habit such as avoid smoking as it has some effect on both cardiovascular and respiratory system. (Luepker, Johnson, Murray, and Pechacek,(1983). * Physical exercise was recommended as well. Previous research has proven that physical exercise and good diet can efficiently control the patient blood pressure.
Patient education: The importance of dieting and exercise is crucial, especially in the modern age we are living in. Staying healthy in America is becoming a serious challenge to most people; cutting down on some fat and going for a weekly physical activities to the gym could make a substantial difference in one’s life. Dieting is so important, considering the amount of carbs and calories the average American consumes each day.
The assessment process is the back bone to any package of care and it is vital that it is personal and appropriate to the individual concerned. Although studies have found that there is no singular theory or understanding as to what the purpose of assessment is, there are different approaches and forms of assessment carried out in health and social care. These different approaches can sometimes result in different outcomes.
PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.
Although medications are very effective, lifestyle and dietary changes can help treat or prevent high blood pressure more effectively.
As with all cardiovascular diseases, Peripheral Arterial Disease can be easily prevented. A good heart healthy diet should be implemented everyday for meals and snacks. A good tip is to include fresh fruits and vegetables everyday. Eating foods low in saturated fat and cholesterol and high in fiber can help prevent high blood cholesterol. Limiting salt or sodium in your diet can also lower your blood pressure. (CDC, 2009) Making sure to get at least 30 minutes of moderate physical activity a day can not only help maintain
2.1 To have an blood pressure maintenance we should maintain a healthy lifestyle, doing some exercises daily and eating healthier,
tells you that he began feeling changes in his heart rhythm about 10 days ago. He has hypertension
As per Healthy People 2020 most Americans do not consume healthy diets and are not physically active at levels needed to maintain proper health. As a result of these behaviors the nation has experienced a dramatic increase in obesity in the U.S with 1 in 3 adults (34.0%) and 1 and 6 children and adolescents (16.2%) are obese. In addition to grave health consequences of being overweight and obese. It significantly raises medical cost and causes a great burden on the U.S medical care delivery system ("Healthy People 2020," 2014, p. 1).
Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.
Assessment is the initial stage of the nursing process. Roper et al consistently use the term ‘assessing’ to signify that it is an on-going process, and highlights its continuity throughout the patient’s episode of care (Aggleton & Chalmers, 2000). It is divided into two stages to allow for a holistic representation of the patient to be established (Barrett et al, 2009). Effective assessment allows the prompt identification of any changes in a patient’s health status, and if necessary; allows any action to be carried out immediately supporting the delivery of safe, effective care DH (). The formulation of an accurate assessment is a fundamental skill for a student nurse as outlined by the NMC (2004), and so it is important that a holistic approach is adopted for this skill to be achieved. An holistic approach supports the consideration of……..needs,(THEME?) which
Assessment in the nursing process will establish the patients' ongoing needs and provide a quality of care best suited to the individual, to achieve a desirable health outcome.
As you learned in NR302, before any nursing plan of care or intervention can be implemented or evaluated, the nurse conducts an assessment, collecting subjective and objective data from an individual. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting both subjective and objective data, synthesizing the data, and identifying health and wellness priorities for the person. The purpose of the assignment is twofold.
The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001). Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission. They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i.e. psychological state and cultural/social standing
The aim of this essay is to demonstrate the assessment process of a patient using the Roper Logan and Tierney (RLT) model of nursing framework and to show how the nursing process works alongside this model. This will be shown by a holistic history of the patient being shown, followed by how the RLT model is applicable to this patient. This is then followed by one nursing intervention being discussed showing how the nursing process is applied to patient care. The patient will be referred to as Mr Frederick Valentine to protect the patient’s anonymity as stated in the Nursing and Midwifery Council Code of Conduct (2008) guidelines.
Obese male. He is 5 feet 7 inches. He weighs 253 pounds. So he is a minimum of his height for 80-90 pounds overweight. Blood pressure on arrival was 149/85, I did retake this it was slightly a little bit lower 139/83, pulse was 75, respirations right around 14. HEENT: Within normal limits. Pulmonary was clear. Cardiovascular: Regular rate and rhythm.
Blood pressure is 116/80, pulse 67, respirations 16, weight 237. Cardiovascular S1, S2. Regular rate and rhythm without murmur. Lungs are clear to auscultation. There is no