Assessments Of Chronic Pain And Mental Impairment

1769 Words Aug 10th, 2015 8 Pages
Assessments of Chronic Pain and Mental Impairment
The objective of performing an assessment is to make a judgment or diagnosis based on the collected data about the patient (Jarvis, 2012). Two important assessments are pain and mental health. This paper will cover both assessments of a female adult patient with chronic pain and an elderly adult patient with mental impairment. Both patients’ health assessment histories, SOAP notes, and summaries of findings will be discussed. The nurse 's responsibility to perform competent assessments requires accurate documentation of patient data and prompt communication to other members of the health care team in order to prevent possible complications or worsening health conditions (Essential Skills, 2001).
Chronic Pain: Health Assessment History
Patitent R.S.’s Medical History consists of End Stage Renal Disease (ESRD) secondary to Diabetes Mellitus Type 2 (DM2) and hypertension (HTN); hyperlipidemia, anemia/iron deficiency/secondary hyperparathyroidism (common dialysis co-morbidities), plantar fasciitis, GERD, and COPD. The Surgical History consists of central venous cathether (CVC) placement 2012, right forearm arteriovenous (AV) graft placement/angiograms/angioplasties, hemodialysis since 2012 L, and heel spur removal 2014. Her Social History includes patient living with adult son who works and also helps with chores at home . She uses public and insurance paid transport. She is independent with ADLs. She denies use of…

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