Physical Comprehensive Assessment Essay.
Final Project The Final Project (6-8 page paper) synthesizes the previous weeks’ study of advanced physical assessment by conducting a comprehensive assessment in ShadowHealth. The final project synthesis is focused upon designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan. Assessment of competency is based on the Comprehensive Patient Interview, Physical Examination and Individualized Plan of Care incorporating Healthy People 2020 and evidence-based interventions and patient-centered goals.Physical Comprehensive Assessment Essay.
You will use one comprehensive digital clinical experience health history and physical assessment for this assignment: Comprehensive Assessment. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. The use of Headers in your paper is strongly encouraged. Submission Parameters: For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 6-8 pages, which does not include the cover page and reference page(s). Introduction (including purpose statement) Subjective Findings Synthesis Objective Findings Synthesis Plan of Care Apply one nursing theory in planning care for this patient Incorporate Healthy People 2020 Objectives into the plan of care prioritized to meet the health needs of the patient Document evidence to support clinical reasoning for selected evidence-based plan of care. Plan of care is individualized to findings, life-span stage of development with culturally specific considerations, and patient-centered. Conclusion References (use primary and/or reliable electronic sources)Physical Comprehensive Assessment Essay.
Physical Comprehensive Assessment
The Shadow Health physical comprehensive assessment aims to illustrate the physical assessment skills and clinical reasoning gained throughout the course. The basis of this learning experience is a 28-year-old female (Tina Jones) who presented for a pre-employment physical assessment. This assignment thus aims to synthesize and analyze the cumulative learning experience by documenting a comprehensive assessment using appropriate nursing theory and integrating the pertinent Health People 2020 (HP2020) goals. Additionally, a personalized and evidence-based care plan sensitive to the cultural considerations and lifespan of the patient will be developed to demonstrate clinical reasoning and judgment.Physical Comprehensive Assessment Essay.
Subjective Findings Synthesis
The patient presented for a pre-employment physical. Her current medications include metformin, Yaz birth control, Albuterol, Fluticasone, Acetaminophen, Drospirenone, Ethinyl-estradiol, and ibuprofen for menstrual cramps. The patient denied any side effects with the medications apart from the metformin which was making her feel bloated but yogurt relieves this.Physical Comprehensive Assessment Essay.
The patient manages diabetes by taking metformin, checking the blood glucose levels daily, and lifestyle modifications. Her blood sugar levels range around 90 and thus the levels are within the normal range (Tayek et al., 2018). She also reports that her asthma is well controlled and inhaler treatment has significantly reduced asthma exacerbations. The patient wears glasses and since then, her sight is great. She further stated that limiting caffeine intake has stopped palpitations and denied any recent incident of back pain. The patient also reports that the oral contraceptive has stabilized her monthly period. The patient notes that she has lost weight due to diet changes and exercise.
Regarding the social life, she is in a new relationship, socializes with her friends, an active church member, and lives with the mother but she is planning to move out in a month’s time. Ms. Jones reports that she has a good support system that includes family, friends, and church members. She admits that she is not under any stress, no depression or anxiety, and she generally feels happy.
her life. She denies any sleep problems or nervousness. Her musculoskeletal system seems okay as she denies any joint or muscle pain. She also denies any dizziness, numbness, or lightheadedness indicating that her neurological system is okay. The cardiovascular system is also okay as she denies any tachycardia or palpitations. The patient also denies any abdominal pain, diarrhea, vomiting, constipation, or nausea.Physical Comprehensive Assessment Essay.
Objective Findings Synthesis
The patient’s vital signs are all stable. The assessment of the respiratory system indicate that her chest is symmetrical, clear breathing sounds to auscultation, while the chest is resonant to percussion. Spirometry readings indicate that Tina’s lungs functioning is normal. Her cardiovascular system is also normal as evidenced by no bruits in the carotid arteries and no lifts or heaves. The capillary refill was less than 2 seconds indicating that the patient’s blood flow is normal (Sansone et al., 2017). The pulse rates are also within the normal ranges and there were no heart murmurs.Physical Comprehensive Assessment Essay.
The patient’s gastrointestinal tract system is normal as indicated by the lack of masses after inspecting the abdomen, no flank pain bilaterally, and tympanic abdomen, and normal bowel sounds within all quadrants. However, the spleens and kidneys were not palpable but the liver was palpable. Assessment of the musculoskeletal system indicated that there was a range of motion in all extremities and while muscle strength, position sense, and motor skills are all within normal limits. The neurological assessment indicates that rapid alternation movements, stereognosis, and graphesthesia are within the normal limits. However, there is reduced sensation to monofilament in plantar surfaces which is an indication of a possible peripheral neuropathy. Therefore, it would be necessary to refer Ms. Jones for further foot examination since she has diabetes and peripheral neuropathy is a common complication in diabetes (Yang et al., 2018). The assessment of nails, hair, and skin indicates no abnormality. However, the acne is visible on the face with abnormal facial hair, and darkened skin in the neck.Physical Comprehensive Assessment Essay.
Plan of Care
Ms. Jones was diagnosed with polycystic ovary syndrome (PCOS) a hormonal disorder characterized by irregular periods, excess androgen (facial har and severe acne), and polycystic ovaries. Obesity is a risk factor in PCOS. Complications in PCOS include infertility, type 2 diabetes, depression, sleep apnea, endometrial cancer, eating disorders, and abnormal uterine bleeding. PCOS is normally treated through birth control pills, lifestyle modifications, progestin, or drugs that promote ovulation (Williams et al., 2016).Physical Comprehensive Assessment Essay.
Type 2 diabetes is a chronic illness that affects the metabolizes of glucose in the body. The prevalence of diabetes type 2 is very high in the US and is among the leading causes of death in the country. Type 2 diabetes normally develops slowly and the symptoms include increased hunger, urination, and thirst, loss of weight, blurred vision, fatigue, frequent infections, slow healing of the wound, and acanthosis nigricans(Davies et al., 2018). Risk factors for type 2 diabetes include more fat in the abdomen, being overweight, lack of physical activities, poor nutrition, old age, and having PCOS. Common complications in diabetes include nephropathy, neuropathy, cardiovascular disease, vision impairment, foot problems, skin conditions, and hearing impairment. The most effective treatment regimen for type 2 diabetes is eating healthy, being physically active, close monitoring of the blood glucose levels, and adhering to the prescribed diabetes medications (Davies et al., 2018).
As per Healthy People 2020, lifestyle modification is the most effective approach to preventing and slowing type 2 diabetes. One of the Healthy People 2020 goals is to ensure effective monitoring of blood glucose levels in adults with type 2 diabetes. Ms. Jones performs regular monitoring of her blood glucose levels (at least once daily), adheres to the prescribed medication, and has implemented lifestyle modifications such as healthy eating and increased physical activities; therefore, she has met this Healthy People 2020 goal.Physical Comprehensive Assessment Essay.
Additionally, another Healthy People 2020 is to increase the number of people with diabetes undergoing annual eye exams. The patient underwent eye examination and was given glasses and thus she has met this Healthy People 2020 goal. Healthy People 2020 also aims to increase the number of people with diabetes undergoing annual foot examinations to ensure the “percentage of people with diabetes has an A1c value of less than 7%”. This means that Ms. Jones needs to ensure annual foot examination and have the A1c levels tested.Physical Comprehensive Assessment Essay.
Ms. Jones is currently overweight because her BMI is approximately 29. A sedentary lifestyle and unhealthy eating habits are the major causes of being obese or overweight. According to Hruby&Hu (2015), risk factors to obesity and being overweight include sedentary lifestyles characterized by inactivity, unhealthy diet, poor education, low socioeconomic status, and age. Complications associated with obesity and being overweight include type 2 diabetes, high cholesterol levels, heart disease, high blood pressures, cancer, sleep apnea, gynecologicalproblems (Surani, 2016). Lifestyle modifications such as increased physical activities and dietary changes are the key treatment approaches towards reducing weight.Physical Comprehensive Assessment Essay.
Culturally, the incidence of diabetes is higher in African Americans and thus Tina Jones is predisposed to diabetes (King et al., 2018). Ms. Jones also presents herself as an independent woman as indicated by the need to work, being professional, and wanting to move out to start living on her own.Physical Comprehensive Assessment Essay.
Dorothea Orem’s Self-Care Deficit Theory stipulates that individuals need to be self-reliant and take responsibility for their health, care, and other close people requiring care. Self-care refers to the “practice activities an individual performs to maintain and promote good health and well-being”. Orem’s self-care theory requires people to maintain an adequate intake of food, air, and water; maintain a good balance between work/activities and rest and a good balance between social interactions and solitude; promote human functioning; and prevent hazards and dangers to life and well-being (Malekzadeh et al., 2018).Physical Comprehensive Assessment Essay.
In addition, self-care means accessing the required healthcare, adhering to the treatment regimen, being aware of the effects of any health condition one has, accepting one’s health status, and learning to live with the condition. Ms. Jones is practicing and adhering to Orem’s self-care theory. This is evidence where she goes to seek healthcare services for example when her menstrual cycle became irregular and seeking treatment for her vision problems. She is also adhering to the prescribed and appropriate treatment regimens as indicated by the positive lifestyle modifications she has made to manage diabetes; adherence to the prescribed medications such as diabetes and asthma medications; wearing glasses, and regularly monitoring her blood glucose levels. Ms. Jones also seems to have accepted her health conditions and appears to be working hard to treat and manage the conditions using the prescribed treatment regimens. Ms. Jones also takes care of her health status as indicated by attending annual gynecological examinations for pap-smear, trying to maintain her vaccinations up-to-date, and practicing safe sex. Accordingly, Ms. Jones manifests positive self-care as per Orem’s self-care theory(Malekzadeh et al., 2018).Physical Comprehensive Assessment Essay.
Ms. Jones presented for a pre-employment physical assessment but she did not have any clinal issues. The assessment indicated that she was healthy apart from the loss of sensation in her feet and high weight. Ms. Jones also has asthma and type2 diabetes, which are well controlled. She should continue losing weight, eating a healthy diet, adhering to the prescribed medications, and monitoring her blood glucose levels. Currently, the only viable health recommendations include Ms. Jones going for A1c testing and a foot assessment.Physical Comprehensive Assessment Essay.
Identifying Data and reliability:
-Occupation: Smith, Stevens, Stewart, Silver & Company
-presents for a pre- employment physical. -She is the primary source of the history. -offers information freely and without contradiction.
-Mrs. Jones Reliable historian
Reason for visit:
History of Present Illness:
HPI: “pre-employment physical” prior to initiating employment.”
Patient Description of current overall health: “feels healthy, is taking better care of herself than in the past”
Fluticasone propionate 110 mcg 2 puffs BID, Metformin, 850 mg PO BID, Drospirenone, ethinyl estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps)
-using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual drops, Benadryl, herbs gingko/garlic/primrose.Physical Comprehensive Assessment Essay.
Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes)
-Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies.
Pap smear (4 months ago), eye exam (three months ago), dental exam (five months ago), PPD (negative, about 2 years ago), wears seatbelt, uses sunscreen.Physical Comprehensive Assessment Essay.
-Acupuncture, chiropractic care, changes in behavior/personality/mood, memory problems, difficulty learning.
Asthma (diagnosed 24 years old), hypertension (resolved with diet/exercise), PCOS (Diagnosed 4 months ago), received childhood vaccinations, meningococcal vaccine (in college), hospitalized in high school for asthma exacerbations (resolved with use of inhaler without complication), tetanus booster (within last year),
-Childhood chickenpox/rubella/polio, serious injuries MVA/broken bones/spinal cord injury, using a walker/cane/hearing aids, appendectomy, tonsillectomy, wisdom teeth removal, transfusion of blood/platelets/red blood cells, current flu vaccine.Physical Comprehensive Assessment Essay.
Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol• Paternal grandmother: still living, age 82, hypertension• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes• Paternal uncle: alcoholism• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.Physical Comprehensive Assessment Essay.
Mental Health History:
Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear.
Review of Systems General:
No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase.Physical Comprehensive Assessment Essay.
Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.Physical Comprehensive Assessment Essay.
Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.Physical Comprehensive Assessment Essay.
Reports no current breathing problems. Reports occasional shortness of breath, wheezing, and chest tightness.Physical Comprehensive Assessment Essay.
Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.
Reports no palpitations, tachycardia, easy bruising, (No Documentation Made) or edema.
Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.Physical Comprehensive Assessment Essay.
Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.Physical Comprehensive Assessment Essay.
Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.Physical Comprehensive Assessment Essay.
Reports no muscle pain, joint pain, muscle weakness, or swelling.
Bilateral upper and lower extremities without swelling, masses, or deformity and with full range of motion. No pain with movement.Physical Comprehensive Assessment Essay.
Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.Physical Comprehensive Assessment Essay.
Strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.Physical Comprehensive Assessment Essay.
Skin, Hair, Nails
Reports improved acne due to oral contraceptives.
Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles
but no other hair or nail changes.
Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.Physical Comprehensive Assessment Essay.