Health Screening And Immunization Guidelines

The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient 's complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained

A 79-year-old female present with her daughter for ongoing fatigue also noted to have lost 5 pounds over past 6 months. No night sweats or fevers. Pertinent past medical history includes severe, generalized osteoarthritis, hypertension, type 2 diabetes mellitus and depression. She is taking the following medications: acetaminophen 650mg every eight hours, Lyrica 75 mg twice daily; alendronate 70 mg once weekly, valsartan 320 mg once daily, fluoxetine 40mg once daily and insulin glargine 20 units once daily. Your exam reveals slight pale conjunctivae, a 2/6 systolic ejection murmur and generalized arthritic joints in her extremities. A point of care test results in a hemoglobin of 10.2 g/dL. Complete blood cell count is done; results

Patient denies chest pain, SOB, N/V/D. Patient is a current tobacco user, denies use of alcohol or illicit

In the Emergency Department, his vital signs showed a blood pressure of 175/89 mmHg, a heart rate of 54 beats per minute, and a temperature of

Health Assessment is a major part of care in the nursing profession. This topic was study in block one during which ten concepts were identified and further analyzed. First, I begin by giving a brief overview of what the concept entails as it pertains to health assessment. Secondly, current research available for each concept is presented. Then application of concepts to the current job (nursing) is given with particular examples of how these concepts can be useful where appropriate. Lastly application of each concept to current world is presented. Throughout the projects various research text are cited when necessary to bring out relevant points.

Blood pressure 122/80. Pulse 76. Respiratory 14. Weight 210 pounds, which is stable for patient.

VITAL SIGNS: Temperature 98.2, pulse 91, respirations 24, blood pressure 158/71, oxygen saturation 95% on room air.

The patient, Don (name changed to protect patient confidentially), was a very pleasant 78 year old male with a medical history consisting of insulin dependent diabetes mellitus, neuropathy with a below knee amputation, high cholesterol and peripheral vascular disease. His current home medications were as follows:

Vital Signs - B/P: 128/82 Temp: 97 Pulse: 80 Resp: 14 O2 Sat 97 %

Undertaking this module of physical assessment has made the author more confident in physical assessment , demonstrating knowledge , skills and judgement in patient consultation, gathering data from a good history taking and developing good communication to establish good rapport with patient and family . The application of skills learned such as inspection, palpation, percussion and auscultation are the major features in physical assessment and are a foundation in the context of care delivery at advanced level. The SOAPIER model used in this assignment has demonstrated an effective working relationship with the multidisciplinary team thereby aiding a successful diagnosis, treatment and plan implementation for a patient with the symptoms

RC is a female of unknown age presented with a chief complaint of a persistent headache. Specifically, RC describes the pain as being located on her skull’s bony ride behind her left ear. The pain is localized to that region, does not travel or radiate to any other areas, and is described by the patient to be felt on her skull bone. The pain is described as being sharp and not dull. RC began noticing the onset of the pain about two months ago and reports it to have gradually gotten worse in severity. The pain gets worse towards the end of the days. The sharp pain makes her feel some “pressure” and “fogginess” in her head as the pain gets worse. Patient does not report any associated symptoms.

Pertinent past medical/surgical history: • Diabetes mellitus • Benign essential hypertension • Hyperlipidemia • PVD (peripheral vascular disease) • GERD (gastroesophageal reflux disease) • Diabetic retinopathy • Osteoarthritis • Glaucoma • Herniated disc lumbosacral • DVT (deep venous thrombosis) greenfield filter (2005) • Adenocarcinoma of prostate s/p resection 1999 • Pulmonary embolism greenfield filter (2005) • GI bleeding intestinal ulcer on Coumadin • Leukocytopenia, unspecified • Chronic renal failure, stage 4 (severe) • Factor V Leiden mutation• Right eye blind• 20/40 vision on left eye• and TKR x three.

Gathering information is needed for assessment so the nurse has to communicate with the patient (primary source), the family (secondary source) and reading files or records of the patient. The nurse also has to observe the client or patient if they are having pain (from facial expressions) or for any behaviors or taking the patient’s vital signs. These observations should be combined with the data that have been collected from the primary and secondary sources. Facts should be précised in order formulate a correct diagnosis which is the second step of the nursing process.

Blood pressure 176/94, pulse 69, respirations 20, temp 97.6, weight 349, O2 sat 98% on room air. Alert male, no acute distress.

The patient’s demonstrated good field of vision by matching the examiner’s field of vision with the confrontation test. She states not currently taking any medications for her eyes. She states no surgical history related to her eyes. There is currently no related laboratory data.