Comprehensive Assessment Results | Turned In

Comprehensive Assessment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Overview Transcript Subjective Data Collection Self-Reflection Explicitly describe the tasks you undertook to complete this exam. Activity Time: 20 min Objective Data Collection Documentation Plan My Exam Student Response: A comprehensive assessment is a complete, all-encompassing, in-depth assessment that includes a complete health history and physical assessment. Components of the health history are the patient's personal history of illness, as well as their family medical history, including any current or prior treatments, surgeries, risk factors, and medications or supplements. In addition, it should include details of other aspects of health, such as the patient’s perception of their health, health beliefs, coping mechanisms, support systems, and functional status. The first question I asked was for Tina to verify her name and date of birth. This is a safety check that assures the assessment I am about to conduct, is on the right patient. It also helps me to determine if this patient is alert to self. Another important question that I started my interview process with was asking the patient the reason for her visit, and if she had any health concerns she would like to discuss. This helps focus the attention on the patient and what he or she needs or hopes to get out of the visit, and also helps guide the interview. Other questions were based on the components of the health history mentioned earlier. For example, I asked Tina how she felt she was doing, to get insight to her perception of health, which can help identify areas of that Tina may need further education on. In addition, I asked Tina what her medical history was, what (if any) medications (OTC, prescribed or supplements) she was currently taking and the reason for taking them, and the dose and frequency. Aside from Tina’s health I asked questions about her personal life, such as who she lived with, what her new job would be, relationship status, and what she enjoyed doing for fun. Again, helping to develop a relationship with the patient, but also providing me with insight to her functional status, support systems, and so on. Other questions asked pertained to risk factors or unhealthy/unsafe behaviors. For example, asking Tina is she currently smoked, or used illicit drugs, or had unprotected sex helps determine if she partakes in unhealthy/unsafe behaviors. Once subjective data was collected, I performed the comprehensive physical assessment, which according to Jensen (2015) should be a complete head-to-toe examination. Head/Neck: I examined the patients head/face for general appearance, symmetry, expression, etc. I assessed her skin, hair, and scalp. I estimated her eyes for equality, pupil response, eye movements, and vision; her ears, nose, mouth, and throat. I palpated her lymph nodes and carotids. I tested her neck strength and ROM. Chest: I examined the patient's chest, in the following sequence, first anteriorly, then posteriorly. First I inspected the pt position and appearance, to see if the patient appeared comfortable. Noting for any signs of respiratory distress. Then I examined the patient's chest for symmetry, size, shape, and muscle use. Next, I auscultated the patient's heart and lung sounds. After auscultation, I palpated PMI, and tactile fremitus anteriorly, and palpated posteriorly for tactile fremitus, symmetry, and expansion and palpated for CVA tenderness; Last, I percussed all lung fields. Abdomen: I examined the patient's abdomen in the following order: inspection, auscultation, percussion, and palpation to include the general appearance of ( scars, masses striae, etc.) symmetry, shape, and size. Explain the clinical reasoning behind your decisions and tasks. Student Response: Student Response: I started this exam by first collecting the health history from the patient, which is subjective data. Subjective data provides insight to the patient and can provide context to how any current problems may be related. Also, personal data collection helps to guide the physical assessment and the nursing process. "The nurse's role in collecting subjective data is to use it to improve the patient's health status and to determine the cause of the patient's current symptoms" (Jensen, 2015). For example, When asking about Tina's medical history I wanted to know if she had any conditions, and if so how long has she had them, the severity of any illness, symptoms, aggravating factors, and if she was currently receiving treatment for it. I also inquired about any allergies, what happens with exposure, the severity of allergies, and how allergies are/have been treated. Other questions I asked included a social history, such as if she smokes and for how long. This helps me to identify any personal risk behaviors Tina may participate in or any environmental risk factors that she may expose herself to. After conversing with the patient, I started to collect my objective data through physical assessment. Before performing the physical assessment, I made sure that the patient was comfortable and that her room temperature was adequate. Also, before starting the nursing comprehensive assessment, I organized my physical assessment from head to toe, instead of systems. This helps the assessment go more smoothly. For purposes of explanation, I will do it based on systems. Of note, The physical assessment is done using four techniques: inspection, palpation, percussion, and auscultation. During the assessment, the patient was told everything that was going to be done before doing it and was assessed for signs of discomfort. Once the assessment was complete, I made sure that the patient was comfortable and had everything she needed, and all of her questions were answered. Neuro- I asked Tina questions to inquire about any risk factors that she may have of developing a neurological condition, such as head trauma and any signs or symptoms of neurological or neuromuscular complications. During subjective data collection an informal neurological assessment was being performed, such as assessing the patient's speech, alertness, etc. Obtaining subjective is important because it provides insight to the patient, and to any potential or current risk factors they may have towards developing or worsening neurological disorders. It also allows for an informal neurological assessment of LOC, speech, general knowledge, etc. This can be helpful in things like determining safety hazards/risks, and when providing education. The cerebellar function was tested by having the patient do a finger-to-nose test and heel-to-shin test. Performing this test not only tests for possible cerebellar lesions/dysfunction but may also help identify safety hazards (such as being a fall risk, or needing assistance at home for an unsteady gait). Sensory function was tested to check for sensory deficits, perception so the patientsclinical situation should be considered when testing it. For example, Tina has diabetes and is more likely to have the peripheral sensory loss. Peripheral sensory from diabetic neuropathy is usually distal, whereas someone with the sensory loss caused by spinal trauma will have sensory loss specific to the area of the skin that is supplied by nerves from the affected spinal root (Jensen, 2015). Testing