Health Assessment In Nursing Free-Samples for Students-Myassignment

Question: You are to complete the admission Assessment for Kasim. Answer: Assessment of the patient situation Patients name: Mr. Kasim AL-Mutar is the name of the client in the scenario. It gives an idea who the person we are dealing with, in implementing the plan of care to avoid misunderstanding when implementing using diagnosis(Forbes, 2015). Gender: he is an old man. Some conditions are gender specific. Age: he is a 49 year old man; age related condition can give a clue on the client management. Also patients needs and management differ with age. Complaint: the patient is complaining of RUQ abdominal pain, vomiting and fever. This is diagnosed as cholecystitis. The medical diagnosis gives the baseline for the management of the client(Jensen, 2014). This complaint is atypical since it mostly affects women as a result to the hormonal composition (estrogen effects on the liver). Also age since it is identified with elderly men of above 75 years of age. Young men are usually asymptomatic. Collecting cues Mr. Kasim AL-Mutar has a HR 126b/min, BP100/45mmHg, temperature of 38.8 severe abdominal pain with last episode of vomiting 2 hours ago. He is also pale with dry mucous membranes and reports a tip shoulder pain rating 7/10. Past medical history and history of use of certain medication is missing in the handing over information(Lewis, 2014). The condition can be a recurrent one may be due to unresponsive to the treatment given earlier or secondary to a certain ailment. Use of over the counter medication gives a direction for the management of the patient pertaining drug interaction and preventing any overdose if the same drug is to be used(Levett-Jones, (2013).). Process information Cholecystitis is the blockage of fluid flow out of the gallbladder by the gallstones causing irritation and swelling of the gallbladder. The patient usually presents with fever, vomiting, pain in the right upper quadrant of the abdomen, nausea and tenderness over the abdomen when touched(Levett-Jones, (2013).). The client presenting with fever, vomiting, right upper quadrant abdominal pain, severe pain at the tip of the shoulder is expected with a client with cholecystitis. Assessment of this client should reveal the following: Clay-colored stool due to absence of the urobilinogen to color the stool, amber urine as a result of excess bilirubin in circulation, jaundice due to unconjugated bilirubin in circulation(LeMone, (2013). Hyperactive bowel sounds due to the increased peristalsis to bypass the undigested fat. Hyper resonant sound on the right upper quadrant of the abdomen due to increased fluid retention in the gallbladder. Tenderness in the right upper quadrant due to the obstructed fluid flow and the inflammatory process (rebound tenderness)(Alfaro-LeFevre, 2014). There is also high temperature as a cardinal sign of the inflammatory process in the gallbladder. Increased apical pulse due to loss of fluid though vomiting, decreasing the cardiac output, as a compensatory mechanism. Problems and issues Cardiovascular system The client is looks pale, presents with dry mucous membranes. The peripheral radial pulse is rapid and pounding while apical pulse is 122b/min. Paleness, increased apical pulse and rapid and pounding peripheral pulse on the client are associated with the decreased cardiac output(Gordon, 2016). ). Also the dry mucous membranes and the clients request for water indicate the lower hydration status of the client. The client is at risk for neurological deterioration due to decreased tissue perfusion(Holland, 2013). Differences in assessment findings for unaffected individual; Assessment technique Assessment findings for cholecystitic client Assessment finding for non cholecystitic client. Inspection Pallor and dry mucous membranes. No pallor and the mucous membranes are pink and moist. Palpation The peripheral pulse is rapid and pounding. The peripheral pulse is palpable and rhythmic. Auscultation The apical pulse is greater than 100b/min. The apical pulse is within the normal rate of 80-100b/min Gastrointestinal system The client experiences pain on the RUQ of the abdomen, nausea and vomiting, there is distention on the right upper quadrant of the abdomen (right and left upper quadrant are asymmetrical)(LeMone, (2013). The bowel movements are increased due to the peristaltic activity working against the undigested fats in the system on auscultation. Also abdominal tenderness and pain is experienced. There is shifting from dull to resonant sound in the right upper quadrant. Acute pain and tenderness is associated with the inflammatory processes in the gallbladder(Gordon, 2016). ). Discomfort caused by the distended abdomen due to the inflammatory process and the fluid accumulation(Gordon, 2016). ). Differences in assessment findings for unaffected individual; Assessment technique GIT assessment findings for acholecystitic client GIT assessment findings for non cholecystitic client. Inspection Distension of the right upper quadrant, asymmetrical The abdomen is symmetrical and Auscultation Increased frequency of the bowel movement. The bowel movement is between is heard between 2-5 seconds. Percussion Pain, and shifting of dull to resonant sound No pain felt on percussion, dull sound is heard. Palpation Abdominal tenderness, organomegally, pain, The organs are soft rounded and no signs of tenderness nor pain. Detail assessment. Biographic data; this is the information that identifies the client like name, age, gender and any other information per the institutional policy(Crisp, 2012). For example, Mr.Kasim AL-Mutar 49 year old man. Chief complain-this is the brief statement in the persons own words for the reasons for seeking healthcare provider(Daines, (2016). ). Mr. Kasim presents following the two days right upper quadrant abdominal pain, fever and vomiting. History of present concern-this is the chronological record of the reasons for seeking health care from the time symptoms started to date(Daines, (2016). ). Mr.Kasim presents with the RUQ abdominal pain and a sharp tip shoulder pain which has lasted for two days. He rate pain on the scale of 7/10. Past medical illness- these are past health event that might have residual event on the current health status. It includes the hospitalization, current medication, allergies and hospitalizations. Mr.Kasims past medical history is missing. Family history-it outlines the conditions that are genetically bound. A genogram clearly shows the information of the family bound illnesses. Lifestyle and health practices profile: it deals with client human response like nutrition, exercise/activity, sleep pattern, medication and substance use, education and environment he lives(Jensen, 2014). This gives an insight of the possible contributing factors to the current health status of an individual. Developmental milestone: a level with a particular problem is identified and comparison made with the normal parameters in the psychosocial developmental stages by Ericksons. Review of systems This is systematic assessment to determine any deviation from normal body functions(Jensen, 2014). Musculoskeletal system- the client experience dry mucous membranes. Neurologic- determine any signs of confusion and lethargy. Respiratory identifying any signs of respiratory distress or shortness of breath. Cardiovascular-feelings of palpitation, heart murmurs and pallor like in mr.Kasim due to decreased cardiac output. Gastrointestinal the patient is experiencing nausea and vomiting, there is abdominal distention. Genitourinary the amount of urine output, discomfort in urination and urgency or hesitancy is noted. Physical examination Complete examination of the client from head to toe noting any deviation from the normal anatomical or physiological functions of the body structure(Forbes, 2015). Inspection, palpation, auscultation and percussion are the four techniques used when conducting physical examination that apply to all the body system in the stated order except in the abdominal assessment (inspection, auscultation, percussion and palpation)(Treas, (2014)). This is to avoid eliciting bowel movement on palpation before auscultation. In conclusion, the patient hydration status is to be met to cater for the decreased cardiac output. Pain management is important to ensure that the clients comfort is addressed as well as maintaining optimal temperature while managing Nursingthe inflammatory process. The overall objective is to improve patients quality of care with an aim of restoring persons maximum functionality. References Alfaro-LeFevre, R. (2014). . Applying nursing process: The foundation for clinical reasoning.: . Philadelphia: Wolters Kluwer Health/Lippincott Williams Wilkins. Crisp, J. T. (2012). Potter Perry's Fundamentals of Nursing - AUS Version. . London: : Elsevier Health Sciences. Daines, J. B. ((2016). ). Advanced health assessment and clinical diagnosis in primary care. mosby: st.lous. Forbes, H. . (2015). Jarviss physical examination and health assessment (Australian and newzealand). Chatswood: Saunders/Elsevier. Gordon, M. (2016). ). Manual of nursing diagnoses (13th ed. Burlington, . Holland, K. . (2013). . Nursing: Decision making skills for practice.: . Oxford: Oxford printing press. Jensen, S. (2014). Nursing health assessment: A best practice approach. (2nd ed.). . Philadelphia:: wolter Kluwer health/Lippicott Williama wikins. LeMone, P. B.-J. ((2013). Medical-Surgical Nursing . Sydney: Pearson Education Australia. Levett-Jones, T. ((2013).). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, NSW: : pearsons Australia. Lewis, P. . ( 2014). . Weber Kelleys health assessment in nursing (2nd Australia and New zealand). North ryde: Lippicott Williams and Wilkins. Treas, L. S. ((2014)). Basic nursing: Concepts, skills, reasoning. . Philadelphia, : PA: F.A. Davis Company.