Subjective Global Assessment Paper

In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.

Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that

Self-assessment usually comes in the form of a questionnaire that identifies the PWS needs through a series of questions about their capabilities and limitations. In xx case, he requires full support with eating, drinking, moving and handling, decision-making, being safe and all other aspects of daily living. Once this has been completed, then it will be shared with the team, social worker, manager, advocate and other important people in xx life.

Considering what specialist help would be beneficial to the child and discuss options with parents/carers

After implementing these strategies, the patient’s weight will be measured and recorded weekly to track the progress (Ramont, Niedringhaus, & Towle, 2012). The level of food intake will also be measured considered plus random questions to determine the memory of the patient. However food intake will be at top of the list, this is because most of the issues surrounding the patient usually have a direct effect on the food intake of the patient. The other technique will be through observation where I will observe whether her joints are healing and whether the inflammation is reducing. Moreover, lack of depression will be determined by how happy she is which is also noticeable through observation (Daly, 2012).

Much of this timing is based on genetics, lifestyle, and access to health care. In general, people have learned stereotypes regarding the elderly. Some of these stereotypes are accurate, but they do not pertain to all the elderly population. Health care providers have come to expect changes in the elderly. However, it is important not to make assumptions, and to use assessment tools to identify changes the elderly may have encountered. Some of the areas the clinician may expect to find changes include: mobility, ambulation, nutritional intake, continence, and skin changes (Tabloski, 2014). The result of these changes includes a multitude of challenges for the elderly. It is important for the clinician to obtain an accurate functional and psychological assessment of the geriatric patient prior to deciding a plan of

(helpguide, 2012) Effective care for older patients requires an accurate assessment of the elderly's health status. Physical, psychological, social, and behavioral and health system factors may influence their health status. Functional health status includes: a) basic activities of daily living; dressing, feeding, bathing, toileting, transfer-moving inside and round the house, b) instrumental activities of daily living; shopping, laundry, cooking, housekeeping, taking medication, managing money, c) advanced activities of daily living; social activity, occupation, recreation. Cognitive function assessment includes: attention span, concentration, intelligence, judgment, learning ability, memory, orientation, perception, problem solving, psychomotor ability, reaction time, social intactness. (ispub, 2012)

Prior to 1975, no federal requirements existed for students with disabilities to attend school, or requirements for schools to attempt to teach students with disabilities (Salvia, Yesseldyke, & Bolt, 2013, p. 25). However, upon the enactment of several federal laws, such as Individuals with Disabilities Education Act (IDEA) and No Child Left Behind (NCLB), student with disabilities received access to free, appropriate public education which in turned required students with disabilities to participate in statewide assessments. According to Public Law 94-142 (now included in IDEA), it requires an individual education program (IEP) for students with disabilities. As part of the IEP, it contains items such as present levels of academic achievement and functional performance, measurable annual goals, criteria of progress, special education and related services as well as documenting any necessary accommodations needed for statewide assessments. The author provides a comparison of statewide assessments including items such as participation, accommodations and types of assessments between the states of Texas and Massachusetts.

Prior to 1975, no federal requirements existed for students with disabilities to attend school, or requirements for schools to attempt to teach students with disabilities (Salvia, Yesseldyke, & Bolt, 2013, p. 25). However, upon the enactment of several federal laws, such as Individuals with Disabilities Education Act (IDEA) and No Child Left Behind (NCLB), student with disabilities received access to free, appropriate public education which in turned required students with disabilities to participate in statewide assessments. According to Public Law 94-142 (now included in IDEA), it requires an individual education program (IEP) for students with disabilities. As part of the IEP, it contains items such as present levels of academic achievement and functional performance, measurable annual goals, criteria of progress, special education and related services as well as documenting any necessary accommodations needed for statewide assessments. The author provides a comparison of statewide assessments, including items such as participation, accommodations and types of assessments between the states of Texas and Massachusetts.

Client reported no known allergies to food or drugs. Client reported that she has 8 years daughter. Client indicated her physical health "average". Client reported that she does not have a current primary care physician at the time of assessment. Client reported that she is not currently pregnant and does not taking medication for medical purpose. Client denied any issues in this dimension. Indicated no current condition or medications that would interfere with treatment. Client exhibited adequate ability to tolerate and cope with physical discomfort. No immediate biomedical services are needed at the time of assessment.

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

Subjective: Client was born on April 11, 1952. According to client, she had history of both eye cornea transplants, and wears contact lenses for both eyes. In addition, she had right elbow dislocation in 2005. Next, client mentioned she is diabetic and currently taking hydrochlorothiazide (HCTZ) and metformin medications for her diabetes and high blood pressure. In addition, client mentioned she regularly visits her primary care physician for regular checkup. Next, client talked about her balanced concerned at gym while raising her opposite leg and arm for exercise. Furthermore, client mentioned that she likes to go at gym four times in a week, and she never has any balance problem during her household chores or dressing. Client lives alone in 3-bedroom house, and she had no steps or stairs in her house. She has a grab bar in her shower and she has step-in shower

I would perform a peripheral vascular assessment on both upper and lower extremities. First, I would inspect and palpate her face and both her arms for color and consistent warmth. Then, I would do skin turgor and assess for capillary refill time bilaterally. Since patient also has vitamin deficiencies, I would at that point inspect her nails. I would move on to palpate her radial pulse bilaterally. Then, I would move to her lower extremities and inspect and palpate for color and consistent warmth. I would then palpate for pretibial edema and pedal pulses bilaterally. After that, I would assess for capillary refill time bilaterally. If there were abnormalities, then I would do a more comprehensive cardiovascular assessment. Patient also has Spina Bifida. I would inspect her back, then have her bend to palpate her spinal curvature. Patient is deaf on her right ear, so I would start out by inspecting and palpating both her ears. I would then do a focus neurological assessment for her ears. I would test for cranial nerve 8, which is acoustic. Since patient has hearing loss on her right ear, I would then perform a whisper test. I would also do a screening of patient’s heart and lung. I would start out by inspecting patient’s anterior chest and cardiac landmark for pulsation. Then palpate and auscultate the patient’s cardiac landmark. If there are no abnormalities I would move on to the lungs. I would note the

Social History: Marital status? What does she do for a living? Does the patient drink alcohol or smoke? Does the patient do illicit drugs? Is the patient have any type of stress? How does the patient cope with

In the case study of the 75 year old woman these are some of the questions that could be added in the assessment process. The relation to the fatigue I would ask more question to get a better understanding in clarifying the direction. Like how long does it lasts when it occurs? Can you rate the level of your fatigue on a scale of 0-10 ten being the worst? Is it accompanied with a type of activity? Have you had any lifestyle changes? It is a gradual or sudden onset? Do you have any sleep disorders i.e. dyspnea? Do you sleep flat or reclined? This helps pinpoint the fatigue from different types. The types of fatigue are tiredness, exercise, depression, stress, medically like anemia, heart disease, emphysema. (Wilson & Giddens 2009)