Health Screening And Immunization Guidelines

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Head to Toe Assessment Nursing assessment is taking a health history and performing if needed, a head-to-toe pattern of inspection, palpation, percussion and auscultation to areas of the patient’s body. This structured and organized manner of assessment helps the nurse to systematically document both the normal and abnormal findings of the examination (Baird, 2006). This paper will discuss the general assessment of different systems of one specific patient and how the clinical findings can aid in summarizing and charting of the data to formulate the plan of care. This paper will also talk about health screening and immunization specific to the age of this patient. Fundamental to this nursing process is how this important step can…show more content…
Vital Signs. The blood pressure is 157/72, respiratory rate 18, heart rate 82, temperature 98.2, and oxygen saturation 100% in room air. Before the examination, the patient’s medical, surgical, social, and family histories, and list of current medications will be collected. The overall picture of the patient’s health condition helps narrow down the differential diagnosis. This can bring about the appropriate interventions to help manage the patient’s problems. Medical History. The patient has diabetes mellitus type 2, end stage renal disease (ESRD) on hemodialysis, anemia and iron deficiency related to ESRD, secondary hyperparathyroidism, renal osteodystrophy, glaucoma, legally blind – past right eye retinal detachment, gastroesophageal reflux disease, arthritis, dyslipidemia, obstructive sleep apnea on CPAP machine, syncope, and cataracts. Surgical History. Patient had EGD and colonoscopy, tubal ligation, central venous catheter placement, left upper arm fistula formation, glaucoma and cataract surgeries, cholecystectomy, caesarean section, bilateral ovarian surgery, and recent spinal surgery after a fall. Social History. The patient quit smoking in 1981. She denies alcohol or illegal drugs. She lives with her husband. She has an adult daughter who helps oversee her medical needs. Family History. Family has non-contributory health history. Assessment: Physical Examination HEENT. She denies any headaches or any head trauma. Head is normocephalic. r. She has a
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