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Health assess 3425 Week1 graded

By amethystjsmn Apr 18, 2015 1482 Words
1

General status, vital signs, pain and nutrition
Name___Kayla Kristen Smith_____________
Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions

Findings

Current Status
1. Allergies
2. Present health concerns

No known allergies
Reports concern of
high blood pressure

Past History
3. Recent weight gains or losses?
4. Previous high fevers, cause, and treatment?
5. History of abnormal pulse?
6. History of abnormal respiratory rate or character?
7. Usual blood pressure, who checked it last, and when?
8. History of pain and treatment?

Recent gain of 10 lbs
Patient denies
Patient denies
Patient denies
120/70, Blood drive
December 2014
Childhood and
adolescent ear
infections treated with
antibiotics

Family History
9. Hypertension?
10. Metabolic/growth problems?
Pain

11. Pain (using COLDSPA)

Patient denies
Has overcome
adolescent morbid
obesity
(Everyone has had
pain at some time or
other-if your patient is
healthy and currently
pain-free, you may
need to use a past
instance of pain.)
Generalized
aching/throbbing in
right greater iliac

2
Character: how does it feel—what sort of pain is it?

region. “It just hurts”

12. Onset:

With running long
distance.

13. Location:

Right hip pain
radiates to back

14. Duration:

Intensifies with
running subsides
after several hours of
rest from exercise.
5

15. Severity (scale of 1 – 10):

16. Pattern—what makes it better or worse:

Pain intensifies with
jogging. Subsides
with rest.
Patient denies.

17.Associated factors—does it cause you to have other
symptoms too?

18. How does pain impact the other areas of life?

2.What are your
concerns about
the pain’s effect on
a. general activity?
Denies concern.
Patient mentions
he “just doesn’t
get to work out
as much or long
as I want to”
b. mood/emotions?
“It is irritating”.
Denies further

3
mood or
emotional
change.
c. concentration?
Patient denies.
d. physical ability?
Admits a decrease
in ability to jog
for cardio
exercise.
e. work?
Patient denies.
f. relations with
other people?
Patient denies.
g. sleep?
Patient denies.
h. appetite?
Patient denies.
i. enjoyment of
life? Patient
denies.

Objective data (General status and vital signs, pain and nutrition) Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, used with permission. Questions

Findings

Current Status
1. Observe physical development (i.e.,
appears to be chronologic age).

Height, stature and build appear to
become consistent with chronological

4
age.
2. Observe skin (i.e., general overall
color, color variation, and condition).

3. Observe dress (occasion and weather
appropriate).

4. Observe hygiene (cleanliness, odor,
grooming).

5. Observe posture (i.e., erect and
comfortable) and gait (i.e.,rhythmic
and coordinated).

6. Observe general body build (muscle
mass and fat distribution).

7. Observe consciousness level
(alertness, orientation,
appropriateness).

8. Observe comfort level-does patient
exhibit visible signs of pain?

9. Observe behavior (body movements,
affect, cooperativeness,
purposefulness, and
appropriateness).

Skin tone is even with no evidence of
vascular or pupuric lesions. a tan color.
Skin is smooth and even. Skin rebounds
and does not remain indented when
pressure is released No edema,
cyanosis, or clubbing present in the
upper or lower extremities. No blanching
seen in fingernails or toenails, pink tone
returns immediately to nails in less that 2
seconds when pressure is released.
Dress is appropriate for the situation and
weather.

Appears to be well-groomed and clean.
Well shaven. Kempt appearance. No
presence of malodor on patient.
Posture is erect and relaxed. Gait is
rhythmic and coordinated with purposeful
movements. Full strength present. No
visible deformities. Muscles are bilaterally
equivalent in strength.
No visible deformities. Muscles are
bilaterally firm and well-developed. Arm
and leg musculature are equal in
appearance with no obvious deformities.
Fat and muscle distribution are evenly
distributed.
Patient is alert and oriented to time,
place, self, and situation. Able to respond
appropriately to conversation and
questions. Patient obeys commands.
Patient does not display any obvious
signs of pain.

Patient affect is responsive and no
blunted. Easily expresses emotional and
is cooperative with questions.
Movements are relaxed and purposeful.
Behavior is appropriate for situation.

5

10. Observe facial expression (cultureappropriate eye contact and facial expression).

11. Observe speech (pattern and style).

Client smiles with relaxed and
appropriate facial expressions. Client
maintains eye contact. Client displays a
full Range of Motion with no presence of
guarding or tension.
Speech is clear and pattern is moderately
paced.

Vital Signs
98.9 F

12. Temperature
13. Heart rate (pulse-- rhythm, amplitude)
14. Respirations (rate, rhythm, and
depth).

15. Blood pressure

58
16-18 breaths per minute. Inspirations
are shallow and nonlabored with no
adventitious lung sounds. Bilateral chest
expansion are symmetrical with each
breath.
118/68.

Nutritional assessment: Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions
Current Status
1. Type of diet (for
instance, low carb,
vegetarian, diabetic,
etc.)
2. Appetite changes
3. Weight changes in
last 6 months?
4. Problems with
indigestion,
heartburn, bloating,
gas?
5. Constipation or
diarrhea?

Findings
Low carb diet.

Denies appetite changes.
Gain of 10 pounds in the past 6 months
Patient denies.

Patient denies.

6

6. Dental problems?
7. Conditions/diseases
affecting intake or
absorption, i.e.,
irritable bowel
disease, gluten
sensitivities, etc.,?
8. Frequency of
dieting?

Patient denies.
Patient denies.

Patient denies dieting. States he does not believe in
dieting but does try to restrict the amount of “carbs I eat”.

Family History
9. Chronic diseases?
10. Weight issues?

Maternal Grandmother breast cancer.
History of adolescent morbid obesity.

Lifestyle and Health
Practices
11. Average daily food
intake—how many
meals and snacks?
12. Approximately how
many 8-oz. glasses
of fluid per day are
consumed?
13. Type of beverages
consumed?
14. Dine alone or with
others?
15. Frequency of eating
out?
16. Do long work hours
affect diet?
17. Sufficient income for
food?
18. List a 24 hour recall
of food intake.

3 meals per day. 3-5 snacks per day.

Patient reports 10-12 glasses per day.

Reports mainly consumes water and 1-2 cups of coffee
per day.
Reports that he dines with family at breakfast and dinner.
1/ per day.
Patient reports stress from work affecting his desire to
take the time and plan healthy meals when he gets off
work. Reports extreme fatigue after work.
Patient states income is sufficient to cover grocery bills.
On 4/10 at 1300: Chilies cheesy fries and pulled pork
tacos
4/10 at 2100: left over pulled pork taco
4/11: 0700 Banana
4/11 @ 1300: ice cream and a diet coke.
4/11 @ 2100: ribs and sausage with mashed potatoes.

7

19. How many alcoholic
drinks per week are
consumed?

Reports intake of 6 beers per week

Objective data: Nutrition assessment
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions

Findings

Current Status
1. Measure height.
2. Measure weight (1 kg = 2.205 lb).
3. Determine BODY MASS INDEX (BMI =
weight in kilograms/height in meters
squared or use the NIH website:
http//nhlbisupport.com/bmi/bmicalc.htm)
. Compare results to BMI in Table 13-3,
on in the textbook. To which category
does your assessment partner belong?
4. Measure waist circumference and
compare findings to Table 13-5 in the
textbook. Which category of risk
captures this person’s situation?

6’0”
88.435
BMI: 26.4
Category: Overweight range

Waist circumference: 36.5
Risk category: at risk

SBAR
Read the instructions and rubric on the assignment form before completing this. As you have assessed your patient, which finding from the “General Status, Pain, Nutrition and Vital Signs” assessment would require attention from the clinician (if it is sufficiently serious to warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle problem? Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing that he/she gets insufficient exercise, is obese, or doesn’t eat a balanced diet—perhaps not as many fruits or veggies as recommended. Most people don’t drink enough water—you can often use that if nothing more serious is apparent. If your assessment partner has chronic health problems or pain, address one of those problems below.

SBAR

8
Situation

Background
Assessment
(Name the problem)
Recommendation

Patient meals consist of low nutrient and high fat
content.
Patient has a history of weight control issues and
morbid obesity in adolescence. Currently struggling to
maintain a healthy consistent diet.
Patient reports stress and fatigue at work affecting his
choices of healthy meal planning. Lack of adequate
sleep and poor dietary intake.
Recommend that the patient follow up with nutritionist or
primary physician to draw cholesterol levels and
possibly look into sleep study to investigate further into
patient feeling extremely fatigued after 6-7 hours of
sleep per night. Recommend patient to get weekly
cardio exercise of 1 hour 3 times/week. Also
recommend patient to spend time at least 1 hour per
week planning grocery trips that consist of patient
buying ingredients to cook quick easy healthy meals.

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