Drew Chapman portfolio



E Folio Health AssessmentFrostburg State University Drew Chapman7/7/14E Folio Health AssessmentAccording to the AACN Baccalaureate Essentials for professional nursing practice these are some of objectives achieved in Health Assessment. Demonstrate the ability to provide quality nursing care to families, individuals, groups, communities, and populations in a variety of settings (American 2008). Demonstrate clinical reasoning within the patient centered care and be able to utilize their knowledge of the human anatomy and how it changes across the lifespan (American 2008). In addition, address patient’s wellness, health promotion, illness, disease management within the nursing practice (American 2008).ExemplarI have chosen to discuss my work on the health assessment history and physical assignment. This is relative and demonstrates the requirements based from essentials IX from the professional baccalaureate of nursing. This assignment demonstrates the many of the outcomes stated in essentials IX Baccalaureate Generalist Nursing Practice such as knowledge, skills, interventions, and education to patients with the acquired chronic disease. ReflectionThe assignment required the ability to acquire knowledge related to wellness, health promotion, illness, disease management and care for the patients. It required that the student be able to assess a patient system by system in a chronological order from head to toe. Knowledge of the physiology of the human body and its systems was required to successfully record and perform a full physical and history which need to be possessed by the student which can be found in under the requirements for essential IX generalist nursing practice. The development of this assignment also required a scientific base of knowledge and nursing intervention which needs to have a basis from evidence base practice. This is also included under essentials IX baccalaureate of nursing.ReferencesAmerican Association of Colleges of Nursing (2008).The Essentials of Baccalaureate Education for Professional Nursing Practice. AACN Board of Directors. Washington D.C 20036 Drew ChapmanDate:5/2/13Patient’s initials:CCChief complaint/reason for seeking care:Hip and back pain, Patients hip and back pain over the past 6 months has been getting progressively worse.Patient describes the pain as a sharp pain that comes and goes . Sometimes it tingles down her leg, which is mostly on the right side. Patient states it limits her mobility. When patient sits for long periods if she gets up fast she has server sharp pain in right hip that lasts a few hours. History of present illness:Yes. Patient states she has had problems with her back since college, age 18. Patient reports her hip pain started about 3 years ago, at age 57.Past medical and surgical history:GERD, Atrial fibrillation, Osteoporosis, Osteoarthritis, hypercholesterolemia, Hip and back pain. Childhood illnesses- mumps, measles, chicken poxNo chronic illnesses reported other than chronic painInjuries/accidents- broken collar bone at age 7, then at age 17. Was in a car accident at age 19 which resulted in no injuries.Patient denies any communicable diseases- HIV, hepatitis A, B, and C, tuberculosis, STD’s.Patient reports no blood transfusionsSpecial needs- Patient uses reading glassesSurgeries- Tonsillectomy at age 13 , cesarean section at age 24, abdominal liposuction at age 40, Allergies:NKAPatient is allergic to latex No food allergiesNo environmental allergiesCurrent medications (Rx & OTC):Oxycodone 5 mg, Hydrocodone 5mg for pain PRN- has been using for 1 yearNexium 20mg for her GERD daily before meals- has been using for 10 years. OTC-Patient takes Motrin 600mg every once in a while for hip and back inflammation/pain- has been using for 20+ years.Alleve 250-500mg – for 20+ years PRNPatient states she uses Marijuana on occasion when her back pain gets bad. Patient denies any other drug use. Pt reports using for 30+ years- smokes 1 time per week.Family health history:Patient’s father had skin cancer basil cell carcinoma, type 2 diabetes and died of lung cancer at the age of 77. Patient’s father as well had COPD. Patient’s mother age 87, father (deseased), sister and brother have high cholesterol. Patient’s sister died of Ovarian cancer at the age of 61.Patient’s mother has the early stages of diverticulitis. Her mother is 88 years old.Patient’s brother has type 2 diabetes, high cholesterol, high blood pressure. He is 67 years old and resides in Mississippi.All 3 of her children are healthy with no medical problems.Patient family has no history of heart disease or cancer that was not caused by smoking.No genetic diseases notedSocial history:Patient has 3 children and lives with 2 of them in Omaha, Nebraska. She has lived there her entire life. Ages of children are 22, 25, 40 years of age. Patient has been divorced for 5 years. Her youngest child has a 9 month old baby girl. Patient lives in a townhome in a middle class neighborhood.Patient has been working as a real estate consultant, adviser, and broker for the past 8 years and before that worked at MCI sciences as an administrative coordinator for the national action plan on breast cancer.Patient has some college level education and has taken several classes for Real estate and received certificates.Patient states she smoked from age 17 to 24. 1.5 packs a day. 10.5 pack years. Patient has not smoked sincePatient states she does not use any illegal substances and never has used; heroin, cocaine, methamphetamines. Except for occasionally she smokes marijuana to calm herself and helps reduce pain.Patient states she has a glass of wine on average of 3 times per week.1. Have you ever felt you should cut down on your drinking? no2. Have people annoyed you by criticizing your drinking? no3. Have you ever felt bad or guilty about your drinking? no4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? NoPatient denies any domestic violence in her life. Patient is not currently dating.Patient states she is heterosexual and menopausal. Patient does not have any sexual partners at this time.No travel historyPatient states she gets adequate amounts of sleep- 6-8 hours per nightSpiritual assessment:Patient states she believes in ghost and frequent watches ghost hunters on TV. Patient states she is very spiritual and has a strong relationship with god. Patient follows the Methodist religion. Patient states there is nothing in her religion or beliefs that could affect the outcomes in her care.Patient states she uses her spiritual and religious beliefs to handle stress.Patient states the meaning of life for her is to be happy and enjoy her time with family.Patient states her beliefs and religion have a lot of importance.Patient states her religion and beliefs do not change how she takes her of her healthPatient states she goes to church every Sunday to a church called Everyday Saints. She states the church supports one another when in need.Cultural assessment:Patient states she has no cultural concerns that can affect her hospitalization. Patient is American, Caucasian.Patient states she has lived in Omaha, NE for her entire life.Patient states her time orientation is future.Patient states she believes the basic nature of human beings is good and evil requiring self control.Patient states the purpose of life is to be happy with the people you lovePatient states human relation’s is a necessity for human socialization.Patient states she believes human being and nature should live as one in harmony.Patient denies any participation in any special activities that are part of her cultural traditions.Patient states she believes that strong work ethic and a positive attitude brings success.Patient states being healthy means exercising and eating foods low in saturated fats and a lot of fruits and vegetables. Patient states she tries her best to get exercise and eat right but her back and hip pain keep her away from the gym. Patient states she will start going to the pool to swim. She states that she maintains her hygiene, is undated with immunizations. Denies herbal drinks, special foods, or wearing charms.Patient states being sick or ill means you need professional medical care that the normal person can help make better. Patient states she believes illness is caused by diseases, bacteria, viruses. She believes her pain was caused by her osteoarthritis and the wear and tear of her body over the years.Patient states she goes to her doctor when she is not feeling well. Patient states she rests and takes her pain medicine and sometimes says some prayers.Patient states she cares for herself mostly when sick. Sometimes her sons help.Patient states she would like to be with her sons when in the hospital and when sick.Patient states she makes her own healthcare decisions and that she has advanced directives and a living will already made.Patient states she has no cultural or ethnic sanctions or considerations related to emotions, feeling, body parts, illness, certain types or surgery.Patient states she doesn’t care who serves her as a healthcare provider- ethnicity or culture.Patient states she reads and speaks English only. Patient does not need an interpreter.Patient states that most of her family live nearby and come visit often.Patient states she handles stress by praying and talking with family and friends.Patient states she is getting really tired of talking about spiritual and cultural things and believes that there is nothing to worry about in regard to her religion, spiritual, or belief system that will affect her care.Patient states it’s ridiculous how many questions we have to ask about spiritual and cultural beliefs.At this point we stopped the spiritual assessment.Nutritional assessment:Height- 5’7” weight- 167 pounds. Waist to hip ratio- waist 36, hip 41. BMI-26Ideal body weight- 130 poundsPatient appears to have a pear shaped body. Patient has mild obesity 20%-40% above ideal body weight.Patient has no signs of poor nutrition such as fatigue, swelling, delayed wound healing on skin, brittle hair, vision changes, eye discharge, mouth sores, headaches, decreased hearing, changes in bowel habits, cramping, frequent fractures, and changes in mood.24 hour food recallBreakfast 8 am- 2 slices of toast, yogurt, and a glass of orange juice.Snack at 11pm- pretzels 1 cupLunch 1pm- Taco bell #1 a burrito supreme and a hard shell taco and a Pepsi.Dinner 5pm- Fish (cod) baked in the oven with asparagus, and boiled potatoes, glass of water with a wedge of lemonSnack before bedtime- homemade Popcorn and a Fresca.Breakfast- 2 over medium eggs, hash browns, and 2 slices of bacon with orange juice.No snackLunch 12pm- Foot long sub from subway- chicken teriyaki with mayonnaise, lettuce, tomato, onions, banana peppers and a bottle of water.Snack at 3pm- Cottage cheese mixed with apple sauce.Dinner 6 pm- Fried pork chops with mashed potatoes and gravy, turnip greens and pinto beans and a glass of red wine.Snack before bedtime- a small bowl of snickers Ice cream.Patient states she has not lost or gained more than 10 pounds in the last month. Patients weight has been stablePatient states she does not follow a particular diet regime and that she eats mostly of what she wants, but is trying to lose a little weight.Patient states she likes healthy and unhealthy foods. Just depends the time of day and her mood.Patient states her strongest cravings are for fast food. She eats at fast food about 3 times per week. And she eats and sit in restaurants about 1 time per week.Patient states she has enough money to buy good food. WNL- within normal limitsHematocrit- 42.1 WNL- within normal limitsHemoglobin- 15.3 WNLHDL-41 lowLDL-131 boarderline highTriglycerides- 134 WNLTransferrin- 180- WNLAlbumin- 4.2 WNLPrealbumin- 25Glucose-84 WNLHbA1c- 5.5%Creatinine- 1.8 WNLHealth maintenance:Sleeps 6-8 hours per nightPt states she eats what she wantsWants to start swimming but doesn’t exercise nowPatient prays and talks with friends and family to handle stressReview of systems:General-Patient feels she general health is good, just has pain issues. Patient denies loss of energy, no unusual body odors, fever, chills, or night sweats.Skin- Skin has no abnormalities. A few moles. Patient doesn’t have rashes, itching, changes in pigmentation, sores, lumps, acne, warts, or any other skin disorders.Hair- Patients hair appears to be thick and strong. Hair is not brittle Her hair has some grey spots. Pt reports no problems with hair.Nails- no abnormalities in her nails. They are not brittle and malformed in any way.Eyes-Patient uses reading glasses. Pt is nearsighted. Denies any other problems in regard to vision or other eye disorders such as blind spots, flashing lights, halos. Pupils are reactive to light (brisk). No drainage. PT reports no problems other than vision. Pt sclera is white, conjunctiva is pink and moist.Hearing- Patient has less hearing in the left ear than the right. PT does not have drainage, pain, light headedness, vertigo ringing in the ears. No unusual odors. Pt tympanic membrane is gray color (normal).Nose and sinus- PT reports no sinus problems or problems with her nose.Mouth- PT states she brushes and flosses her teeth twice per day. PT had filling done 30 years ago for cavities. Patient denies any problems with oral cavity- tongue, teeth, gingivae.Throat and neck-PT denies any changes in voice, sore throats. Pt had tonsillectomy many years ago. Pt states she has stiffness in her neck about once a month. Pt describes the pain as dull and achy which lasts up to a day. Breast and axilla- Pt denies pain or tenderness in breasts. No lumps or change in size. Last mammogram was 3 years ago.Respiratory-PT denies any respiratory problems. Pt lungs are clear during inspiratory and expiratory breaths.Cardiovascular and peripheral- Pt states she has atrial fibrillation. Denies chest pains, syncope, edema, no Hx of MI, Hypertension, or DTV. Pt had an EKG 2 years ago. PT uses 1 pillow to sleep.Gastrointestinal- Pt states sometimes she gets constipated from her pain medicine, but other than that she has no problems with her GI. Hx of GERD which she takes nexium 20mg.Urinary-Pt denies any change in Urinary habits. Pt states urine is clear yellow.Musculoskeletal- Pt broke her collar bone 50 years ago. Pt states sometimes she has muscle spasms in her back that last a few seconds. Sprained her ankles a few times.Neurological-Pt denies headache, loss in sensory perception, incoordination, seizures, weakness or paralysis. Psychological- pt denies any issues regarding psychological.Female reproductive-Last menstrual period was at age 51. Pt denies any bleeding or discharge from the vagina. Pt had 3 pregnancies: 2 vaginal and 1 c-section ( due to being breech).Nutrition- Pt likes all types of foods- healthy and unhealthy. Pt weight has been stable. Pt is diary intolerant- causes flatus. Pt drinks 1 cup of coffee per day.Endocrine- Pt denies any problems with her thyroid or parathyroid glands. Pt denies excessive sweats, increases in water and food intake. No diabetes or increase in the size or hands or feet.Lymph nodes- no enlargement or tenderness in lymph nodes.Hematological- Pt states she has no known blood disorders, no excessive bruising, anemia. Pt states she is blood type B -.Physical examination:This is a report on a pleasant 60 year old female with initials CC. She appears to be of apparent age of 60. She is of pear shape body. Pt has good posture and her limbs and they are in proportion to her body. Her gait is a little deviated due to the right hip pain and back pain that has been a chronic issue for her. PT is well groomed and demonstrates good hygiene, no unusual body odors. Pt is answering questions appropriately and is calm and cooperative with the physical examination. Pt demonstrates appropriate speech and facial expressions. Pt does not appear to be in any physical or psychological distress at this time. Pt reports pain in right hip and lower back in the region Lumber 3 and 4, rating the pain on a scale from 1-10 the pain being a 7.Vital signs- Blood pressure- 128/64 left arm, Heart rate- 83 radial, Temperature- 98.9 oral, Respirations- 16, Spo2- 98%Pt is alert and oriented x 4. Behavior is appropriate for situation. Pt is able to recall the times of onset of pain and how the injuries occurred.Eyes/ neurological- Eyes are round and reactive to light. Pupils are 3 millimeters in diameter. Pt is able to perform vertical and downward gazes, left and right lateral gazes, and diagonal from left to right. Pt is able to stick out tongue and shrug her should with resistance. Pt affect is cooperative and calm but on occasion Pt appears to be in pain. Short-term and long-term memory is consistent with written information. All cranial nerves appear to be intact. Denies any other problems in regard to vision or other eye disorders such as blind spots, flashing lights, halos. Pupils are reactive to light (brisk). No drainage. PT reports no problems other than vision. Pt sclera is white, conjunctiva is pink and moist.ENT/mouth- Both ears appear to be symmetrical, no signs of infection, no drainage, no excess wax. Pt is able to pass the whisper test. Visualization of the ear canal, I can visualize the tympanic membrane and appears to be in normal condition- gray color no swelling or signs of infection. Weber and Rinne tests were performed. Pt has a significant loss of hearing in her left ear via air conduction.PT is able to identify the smell of coffee. Nasal patency bilaterally is clear and the external surface of the nose is normal. Frontal and maxillary sinuses do not show any signs of abnormality. Pt breath odor is normal. Pt lips and buccal mucosa, gums and hard and soft palates appear health- pink and moist. Pt has several fillings in her molar teeth. Pt able to stick out tongue and movement of the uvula was noted. Tonsils appear to be removed. Gag reflex is intact and Pt is able to taste food. Musculature of the neck is normal, trachea is midline. Carotid arteries are palpable. Pt denies bleeding from the ears, nose and throat. Pt lymph nodes feel small and disseminated- no enlargement or tenderness. Pt trachea is mid line.Respiratory- Pt respiration’s are regular and unlabored. Upon auscultation all lobes of the lungs were clear. Chest rise and fall is equal. Trachea is mid line. SPo2 was 98% on room air. Pt does not have any wheezing, crackles, or rales.Cardiovascular- Pt heart is in regular rhythm. EKG shows atrial fibrillation. Pt radial, popliteal, carotid and pedal pulses are palpable. Pt denies chest pain. Pt does not have any lower extremity edema. Pt denies palpitations, no orthopnea. Pt capillary refill less than 3 seconds.Gastrointestinal- Pt abdomen appears to be soft and round. Pt denies tenderness in abdomen. All 4 abdominal quadrants have normoactive bowel sounds. Pt reports 1 bowel movement per day. Pt denies rectal bleeding and flatus present. Genitourinary- Pt denies incontinence. Pt has no flank pain with percussion. Pt reports clear yellow urine. Pt does not report any changes in color, odor of urine or frequency. Hematologic/lymphatic- Lymph nodes in neck and axilla normal; no tenderness or enlargement. Pt denies any blood disorders. No bruising found on pt. Labs show anemia is not present.Musculoskeletal- Pt does not present with any bone or muscular deformities. Pt gait is slightly limped due to right hip pain and back pain. Pt left foot has hammer toe.Skin- Skin has normal skin elasticity. Pt has a large scar on her right knee. Pt skin is warm to touch. Nail beds are pink and firm, no clubbing. Pt skin does not have any rashes, no itching, no change in skin pigmentation. Pt does not have any sores or acne.Psychological- Pt denies depression, irritability, or recent mood changes. Pt does not report any recent life changes or thoughts of hurting themselves or others. Pt is pleasant and cooperative with the examination. Pt maintains eye contact and has appropriate speech.Nursing diagnoses, patient goals, interventions:Chronic Pain related to Hip and back osteoarthritis and past injuries evidenced by patient verbalization of pain.Goal- Patient will use medications to control pain and patient will verbalize a pain rating of less than 3 on a scale of 1-10 on a regular basis by 5/24/13.Nursing intervention- Instruct patient to start swimming and eat balanced meals to promote weight loss Nursing intervention- Take prescribed pain medicine before the pain increases in severity.Impaired Mobility related to hip and back pain evidenced by patient limping with ambulation.Goal- Patient will be able to ambulate normally without any limitations or walk with a limp by 5/24/13.Nursing intervention- Teach patient how to do passive and active range of motion exercises 2 times daily.Nursing Intervention- As last resort if pain does not improve will refer patient to orthopedic doctor for surgery consult. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download