Assesment 6 – Before any nursing plan of care or intervention

Assesment 6

Purpose

Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the individual through the collection of both subjective and objective data. 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 subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings. The purpose of the assignment is two-fold:

· To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and developmental) affecting health and wellness.

· To reflect on the interactive process between self and client when conducting a health assessment.

1. Include the following sections when completing the paper.

a. Health History Assessment (70 points/70%)

1) Demographics

2) Perception of Health

3) Past Medical History

4) Family Medical History

5) Review of Systems (each system in the review of system sections should have level 2 headers)

6) Developmental Considerations- use Erikson’s Stages of Psychosocial Development- which stage is your participant at and give examples of if they have met or not met the milestones for that stage.

7) Cultural Considerations- definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine, these are examples but please add more

8) Psychosocial Considerations- support systems-family, religious, occupational, community these are examples but please add more

9) Collaborative Resources to Improve Health- give examples of resources available to improve the health of the participant such as community, nutritional recommendations, healthcare, spiritual, etc.

b. Reflection (20 points/20%)

Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health History.

1) Reflect on your interaction with the interviewee holistically.

a) Describes the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.

2) How did your interaction compare to what you have learned?

3) What barriers to communication did you experience?

a) How did you overcome them?

b) What will you do to overcome them in the future?

4) What went well with this assignment?

5) Were there unanticipated challenges during this assignment?

6) Was there information you wished you had available but did not?

7) How will you alter your approach next time?

2. Style and Organization (10 Points/10%)

Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information, and appropriate writing skills. Scoring of your work in written communication is based on proper use of grammar, spelling, APA, and how clearly you express your thoughts and reasoning in your writing.

1) Grammar and mechanics are free of errors.

2) Verbalizes thoughts and reasoning clearly.

3) Uses appropriate resources and ideas to support topic with APA where applicable.

Directions: Obtained health history from individual. Documented findings below.

Student Name:   Patient Biographic Data	Date – 1/9/2024	Patient Initials MR
Initials MR Age 24	Marital Status single Occupation nurse	Race/Ethnicity Asian
female Gender	Religious preference	hindu
5’4 Height   Reason for seeking care	Weight 130
Rapid heart rate, nausea dizziness, started two days ago, goes away comes back, gets once a day or twice. 150/160 heart rate, chest hurting, 10-15 minutes, during the day, first time after she ate, happened 3-4 hours later after breakfast, asthma after covid

Present health or history of present illness

Pcls, asthma after covid,

Past Medical History

Svts, pcls, heart murmur, heart burns occasionally

Immunizations Up to Date: yes

Tobacco Use NO Alcohol use Once a week, glass of two or wine

Illicit drug use: NO

Allergies

NO ALLERGIES

Current Medications

Birth control , OTC vitamins

Family History

Mom’s mom have diabetes, hypertension, high cholesterol. Mom’s dad has diabetes. Dads parents have high cholesterol. Mom and sisters have thyroid issues,

Review of Systems (The focus of the ROS is to discover current and past information about each body system through a series of questions. Certain questions should only be asked of those who fall into a particular risk category. For example, you would not ask a female teenager about menopause or a male teenager about prostate problems)

1. Skin and Nails (History skin cancer, Itching, Bruising, Rashes, Change in hair or nails)

Random bruises on legs,

2. Head and Neck (Headaches, Head injury)

no

3. Eyes (Glasses or contacts, Change in vision, Eye pain, Double vision, Flashing lights, Glaucoma/cataracts)

Glasses and contacts, eye pain in the sun,

3. Ears, Nose, Mouth, and Throat (Impaired hearing, Use of hearing aids, Ringing in ears, Seasonal allergies, Nose bleeds, Colds, Bleeding gums, Dentures/partials, Sore throat) – Thyroid are enlarged,

4. Respiratory (Shortness of breath, Cough, Wheezing, Pneumonia, COPD, Chronic bronchitis)

No

6 Cardiovascular (CAD, Irregular rhythm, Murmur, Pacemaker, Stents) Rapid heart rate, previous heart murmur,

7 Peripheral Vascular (Leg cramps, varicose veins, Clots in veins)

8 Abdomen (Change in appetite, N/V/D, Constipation, Abdominal pain, Rectal bleeding)

9 Urinary (Difficulty urinating, Pain or burning on urination, Frequency or urgency, Incontinence, Dribbling, UTI/stones)

10 Neurologic (Seizures, Weakness, Tremor, Numbness, Stroke)

11 Musculoskeletal (Pain, Stiffness, Arthritis, Gout, Decreased joint motion, Fractures)

12 Reproductive (Last menstrual period, Pregnancies, Miscarriage, Menopausal, Self-testicular exam, Prostate)

13 Breast and axillae (Last mammogram, Self-breast exams, Implants)

 

During this exercise, were you obtaining subjective or objective data?

EXAMPLE OF HOW PAPER SHOULD BE WRITTEN… SCROLL FURTHER DOWN TO SEE:

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