Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.Advanced Health Assessment Essay
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.Advanced Health Assessment Essay
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
The Assignment. Follow he Rubric. At least 3 matching References and citations.Advanced Health Assessment Essay
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
CASE STUDY 3: Focused Ear Exam
Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool.Advanced Health Assessment Essay
Excellent Good Fair Poor
Using the Episodic/Focused SOAP Template:
• Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.
• Provide evidence from the literature to support diagnostic tests that would be appropriate for your case. 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 33 (33%) – 38 (38%)Advanced Health Assessment Essay
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
• List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected. 24 (24%) – 29 (29%)
The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected. 18 (18%) – 23 (23%)
The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 0 (0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.Advanced Health Assessment Essay
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 0 (0%) – 2 (2%)Advanced Health Assessment Essay
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)
Uses correct APA format with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) Advanced Health Assessment Essay
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
• Chapter 11, “Head and Neck”
This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.
• Chapter 12, “Eyes”
In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.
• Chapter 13, “Ears, Nose, and Throat”
The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.Advanced Health Assessment Essay
Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.
Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.
Chapter 25, “Nasal Symptoms and Sinus Congestion”
In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.Advanced Health Assessment Essay
Chapter 30, “Red Eye”
The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.
Chapter 32, “Sore Throat”
A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.Advanced Health Assessment Essay
Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.
40 year old Black male, recent Immigrant from Africa without Health Insurance.
How would your communication and interview techniques for building a health history differ with each
How might you target your questions for building a health history based on the patient’s social determinants of health?
What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.Advanced Health Assessment Essay
By Day 3 of Week 1
Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
Despite the importance of an individual’s perspective of their health and wellbeing, individuals are extremely influenced by the extent to which their treatment outcomes meet their expectations (O’hagan et al., 2014). This is why it is important for nurses to incorporate the individual’s perspective into the interventions; to accomplish this nurses need to use effective communication, such as verbal and non-verbal techniques, to receive the appropriate subjective health information (O’hagan et al., 2014). Nurses further must implement the individual’s perspective into the development of nursing interventions; this will help influence a positive recovery (O’hagan et al., 2014). This essay will define communication in the context of nursing; it will discuss the process followed regarding the selection of an individual and the arrangements made, also which interview techniques were utilised. The essay will further discuss the health strengths of an individual, as well as any health concerns which may benefit from health promotional education. Lastly, there will be a summary about what I learnt from this assignment.Advanced Health Assessment Essay
It is crucial to understand the importance of communication in the context of nursing, in order to implement it in a nurse-client relationship. Communication is central to human interaction, as it allows individuals to establish, maintain and improve contact with each other (Juvé-Udina et al., 2014). The word communication originates centuries ago from the Greek word “communis” meaning to make common (O’hagan et al., 2014). Tay, Hegney and Ang (2011) define communication as ‘a two-way process –sending the right message that is also being correctly received and understood by the other person’. Communication in the context of nursing is where the nurse and patient perceive the other in the situation and, through communication of verbal and non-verbal messages, sets goals, and agrees on interventions to help achieve these goals (Tay et al., 2011).Advanced Health Assessment Essay
The initial goal for this assignment is to find a healthy individual between the ages of thirty and sixty five who is not a friend, family member or anyone I knew well. This was achieved by ringing my aunty and asking if she knew anyone in the area that would be happy to help with my assignment. My aunty gave me the phone number and the email of a colleague; from here I sent an email explaining the “subjective health assessment” project to her. Jenny (pseudonym) promptly replied saying she would be happy to assist, when she agreed I emailed her a consent form. I also ensured her that to be in accordance with The Nursing Council Code of Conduct (2012) as a student nurse I must respect her rights to confidentiality and therefore any personal or identifiable information will be altered to protect her privacy and dignity. From here we arranged to have the interview take place at her house as it would not only be private but it would help ensure that she feels comfortable, we worked out a time that suited us both and decided at 10am on Wednesday 30th of July.Advanced Health Assessment Essay
The quality and reliability of information is influenced by the way in which information is collected, which is related to the use of nonverbal and verbal communication (Jarvis, 2012). Nonverbal communication of appearance, demeanour, facial expression, silence, and listening are highly influential. I incorporated all these aspects into my interview. Firstly I wore my nursing uniform which made my appearance look professional, and kept a neutral friendly expression throughout the interview. I also made sure my attitude was non-judgemental and that we were seated at eye level; this helped to maintain eye contact which showed that I was alert and listening to her. Sitting at eye level also helped make us both feel equal as no one had an authoritative role over the other. However, verbal communication is just as important as nonverbal communication. I ensured that all the questions I asked were open ended this allowed Jenny to expand in areas which provided me with relevant and detailed information. Also, by using the communication technique refection I was able to respond in a way that allowed Jenny to realise that I was listening and understanding what she was communicating.Advanced Health Assessment Essay
June has the belief that, for her age she is healthy and she is content with her current level of health. She lives a healthy lifestyle and has few health issues. Junes health and wellbeing is supported by having had completed all of the immunisation programs recommended for her through her childhood. These immunisations are very important during an individual’s childhood as it protects children from negative impacts of illness (Grant, Luxford, & Darbyshire, 2005). However, even though June completed these immunisation programs she still contracted chicken pox at seven years of age. This is an extremely contagious disease which is spread by the same methods as the common cold such as coughing, sneezing and skin to skin contact (Grant, Luxford, & Darbyshire, 2005).Advanced Health Assessment Essay
There are many things that influence an individual’s overall health, and the likelihood of developing diseases (Jarvis, 2012). Diseases can occur due to a combination of genetic, lifestyle and environmental factors (Jarvis, 2012). In the context of Jennys health she is unaware of any hereditary diseases in her family history. This is a great strength to have as Jenny does not have any increased risks of getting genetic disorders or passing them onto her children. Another strength Jenny has is that she works on a farm; this means she is often outdoors in the natural environment. Tardona, Bozeman and Pierson (2014) research indicates that exposure and experiences in natural environment can improve wellbeing by increasing self-esteem, spiritual well-being, cognitive functions and relieving stress. This shows that Jenny is free of health illnesses and her job contributes to her overall wellbeing Peterson (2000) discusses how this is a proven benefit not only to the individual but the family as well.Advanced Health Assessment Essay
Regular exercise and sleep patterns are more beneficial strengths displayed by Jenny which contributes positively to her overall wellbeing. Ekblom-Bak, Ekblom, Vikström, De Faire, and Hellénius (2014) discusses how at least 150 minutes per week of moderate to vigorous exercise is important for maintaining a healthy lifestyle. Jenny well and truly does more than 150 minutes per week as she motivates herself to go for a power walk every day for around an hour. Kemmler and Von Stengel (2013) research shows that there is a lower chance of experiencing heart disease, some cancers, stroke and type two diabetes when regular exercise is implemented into everyday life. Exercise further helps to improve sleeping patterns. As Jenny is a farmer she has to wake up at 5am most mornings, this results in Jenny having to manage her time well to make sure she gets enough sleep. Jenny goes to sleep around 9.30 at night usually without waking throughout the night and does not nap throughout the day this shows Jenny has healthy sleep patterns. According to Gruber (2013) healthy sleep patterns are shown to have a positive impact on an individual’s body as it enables the individual to cope with everyday living tasks.Advanced Health Assessment Essay
Musculoskeletal disorders are the main representation for absence at work worldwide, Jenny experiences back pain which is increased by stress (Lövgren, Gustavsson, Melin, & Rudman, 2014). Lundberg and Melin (2002), look at how the conditions at work, such as time pressure and heavy lifting, can contribute to elevated stress levels and muscular tension. They further explore how the elevated levels of stress can reduce the time for rest and recuperations (Lundberg & Melin, 2002). Therefore it is important for Jenny to implement interventions that help improve her back pain, when Jenny is at work she could limit the amount of heavy lifting she does and also be educated on the correct lifting technique to avoid further injuries or strains to her back. Jenny can further implement the use of over the counter medication such as deep heat to help relieve the pain and tension in her muscles.
The increasing instability in the economic sector and the increase in unemployment rates are likely to trigger financial worries, which can contribute to fatigue levels (Stewart, Abbey, Meana & Boydell, 1998). This is because financial worries present themselves as a psychological threat which is prolonged and chronic in nature. This causes an increase in fatigue levels as our bodies are not designed to cope with prolonged periods of increased stress hormone (cortisol) levels (Stewart et al., 1998). In Jennys context she has a job however she still feels financially unstable which could be related to her increased levels of fatigue. Therefore Jenny needs to implement interventions such as seeing a financial consultant to help her understand her future options and avoid finical crisis.Advanced Health Assessment Essay
Through completing this assignment I feel I now have a greater understanding of the importance of communication in a nurse-client relationship. I learnt that without using proper communication skills you will be unable to understand the individual’s perspective of their health and what they want in life. What I found is that by being non-judgemental and honest throughout the interview developed the nurse-client relationship more, which is extremely important with the client as they are the primary source of information. I believe this was shown when Jenny felt respected as she opened up more by telling me more about her life instead of answering briefly. I further understand the importance of asking open ended questions and using non-verbal communication skills as if I had not the information I received would have been different. I also learnt the importance of taking your time and just listening to the client, especially in Jennys case as she got very excited talking about her children and upset when I approached the subject of finical stability. So from this I understood that her major worries and weakness in her life is to do with finical pressure and that her children provide her with a source of happiness.Advanced Health Assessment Essay
In conclusion, effective communication provides nurses with a way to gather information from a client successfully. This essay looked at how I went about selecting an individual and the arrangements made. While also disusing how non-verbal techniques of eye contact and appearance helped make Jenny feel comfortable and verbal techniques of open ended questions to receive more relevant detailed information. This essay further suggested that Jenny’s strengths included having a healthy childhood, no hereditary diseases in the family history, working on a farm and having regular exercise and sleep patterns. However Jenny’s weakness of back pain and feeling financial unstable can lead to health issues which is why interventions of education of proper lifting techniques, using deep heat and seeing a financial advisor can help Jenny’s overall health. This essay also looked at what I learnt from completing this assignment which was that communication skills majorly affect the quality of the information gathered and the trust between a nurse and a client. Advanced Health Assessment Essay
Get your Plagiarism-free essays from Tutorsgallery.com