Benchmark Assignment Individual Client Health History and Examination Essay
During my medical-surgical clinical experience, I managed a 58-year old patient who had a left leg amputation. The patient had presented with loss of sensations on the left foot and skin-color change in the left leg. The patient was a known Diabetic for 14 years and had a history of high blood pressure. On physical examination, the left leg was gangrenous, and there was a loss of sensation. The patient was reviewed by a podiatrist and a surgeon who recommended an urgent amputation of the leg. The patient’s condition could have been prevented through education on Diabetes self-management and regular screening by a podiatrist (Jarvis, 2020). Education on foot-care could have prevented him from the suffering and morbidity associated with limb amputation (Jarvis, 2020). The patient history of high blood pressure can be prevented through health education on lifestyle modification, regular screening, and treatment of hypertension to prevent hypertensive complications.
One of my roles is to be the patients’ advocate by ensuring that they receive the best care possible, which is affordable, equitable, and culturally sensitive. Patient advocacy can involve helping the patients make informed decisions on matters affecting their health (Gerber, 2018). I can explain to them the benefits and risks of a treatment procedure and medication and help them make ethical choices. I can also advocate for the rights of the patients’ by facilitating their needs and making them a priority regardless of the family’s wishes (Gerber, 2018). Moreover, I can provide health education on self-management of chronic illnesses and prevention of complications to promote their quality of life and prevent morbidity (Gerber, 2018). I can further advocate for the provision of the same quality of care to all patients in the facility regardless of their race, socioeconomic status, religion, and insurance status.
Gerber, L. (2018). Understanding the nurse’s role as a patient advocate. Nursing2019, 48(4), 55-58.
Jarvis, C. (2020). Physical examination & health assessment (8th ed.). St. Louis, MO: Elsevier
Leadership Council website athttps://www.ihs.gov/nnlc/includes/themes/newihstheme/display_objects/documents/resources/SBARTEMPLATE.pdf as a guide.
CURRENT HEALTH STATUS:
JH considers him self to be a somewhat health person besides his illness and hospitalization 2 years ago. To stay healthy, JH admits to exercising regularly and being aware of his diet. He admits to visiting a health care provider regularly and attends cardiac rehab twice per week. JH admits that his health has been very good over the past year as he continues to recover from his heart disease. In early 2012, he had been hospitalized for two months with an infection around his heart. Patient admits to smoking in the past but quit two years ago. He continues to drink a couple glasses of red wine at dinner everyday. Patient takes a prescription medication for his Blood Pressure along with OTC antacids and allergy medications but does not remember the names. JH is allergic to pollen, walnuts, dust and mold. He admits to being UTD on all medications including influenza, shingles, hepB and pneumococcal. Patient wears his seat belt every time he is in the care and has never had any accidents nor been involved in one. He denies knowing first aid/CPR.
JH attends cardiac rehab twice a week, exercising on the recumbent bike, hand weights and sometimes the treadmill. He does not like using the treadmill. His leisure activates used to include skiing but since his hospitalization he has slowed down on this activity. He now enjoys sailing in the summertime. JH has a shoulder pad prosthesis since the amputation of his right clavicle/ scapula for osteosarcoma in 1962. He denies needing a cane, walker or wheelchair.
JH admits to sleeping 6.5-7 hours per night and wakes up feeling rested. He denies napping during the day. He retires at 9:30pm and awakens at 4:45am. He denies any problems with sleeplessness and the used of sleep aids.
BP:120/60 Radial Pulse:_________ Rhythm: A-fib/flutter
JH admits to chest pain and SOB. He denies cough, distended neck veins, edema, cyanosis and varicosities.
JH speaks English. He claims he used to have bad migraines but doesn’t anymore. He has had 2-3 seizures a couple years ago but has been sense treated. Patient admits to having balance problems in the past. He wears glasses for reading. JH denies problems with dizziness, speech impediment, walking and visual problems. He does not use a hearing aid. UTA date of last hearing or eye exam. He denies any problem with memory.
Height: 6’2.5” Weight 165 lbs
JH eats three full meals a day and denies snacking. He admits to not drinking enough water. He does not have dentures but has crowns. His last dental exam was a couple months ago. He denies weight loss and weight gain. JH is allergic to walnuts. He denies GI bleeding, difficulty swallowing, nausea, vomiting, anorexia and bulimia.
JH’s friends would describe him as friendly, positive and sometimes funny. His source of strength and hope comes from God and his family and friends. He attends church at least once a week but often times multiple times per week.
PH admits that his health problems have affected his skiing but he has not stopped completely. He denies feelings of anger, fear, anxiety and depression but says the biggest negativity in his life is his impatience. He deals with this but just brushing it off and occasionally swearing. The only significant loss/change in this life was his hospitalization two years ago. If he could changes one thing to improve his quality of life it would be to be more generous.
Patient denies his cultural background affecting his health care needs. He is Caucasian with his cultural background being English and Irish. His family shows they care by giving hugs and kisses.
ILLNESS BELIEFS AND CUSTOMS
JH said that people become ill when they are ill or when there is a lot of tension. When he is sick, he likes to pray, relax and tries to be patient, When his loved ones are sick he prays for them, cares for them and is there for them.
JH defines his family as terrific. He has four adult kids and a wife of 47 years. He denies specific duties for men women and children in a family. Growing up both him and his wife disciplined the children but now they live alone and take care of themselves and their families. JH admits that the most important aspect of life is leading a good life full of gratitude. There are no topics not discussed in their household. In his home they only speak English. JH is a self-employed attorney. He admits to finances influencing his life. He graduated form law school. His wife and three of his children graduated from college one having his doctorate.
APA format is not required, but solid academic writing is expected.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are not required to submit this assignment to Turnitin.
Assignment Details – NRS 434V Week 5 Benchmark Assignment – Individual Client Health History and Examination
For this Assignment, you are going to write a paper explaining how you developed your theory through the four stages (theorizing, syntax, theory testing, and evaluation). Your paper must be 3 to 5 pages, not including the title and reference pages. NRS 434V Week 5 Benchmark Assignment – Individual Client Health History and Examination.
To view the Grading Rubric for this Assignment, please visit the Grading Rubrics section of the Course Resources.
Before finalizing your work, you should:
- Minimum requirement of at least 5 sources of support
- be sure to read the Assignment description carefully (as displayed above);
- consult the Grading Rubric (under the Course Resources) to make sure you have included everything necessary; and
utilize spelling and grammar check to minimize errors.
NRS 434V Week 5 Assignment 2 – Health Assessment Presentation
NRS 434V Week 5 Assignment 2 – Health Assessment Presentation
In this assignment, you will be creating a PowerPoint presentation based on the application of the functional health assessment of a movie character. To complete this assignment, choose a movie from the following list and identify a character from the movie on whom you would like to do a health assessment. If you wish to use a character from a movie not included on the following list, get the approval of your instructor.
1. Away From
3. Lorenzo’s Oil
5. My Sister’s Keeper
7. Rain Man
8. Steel Magnolias
10. The Elephant Man
11. The Mighty
12. The Tic Code
Directions for NRS 434V Week 5 Assignment 2 – Health Assessment Presentation:
1. Create a PowerPoint presentation of 10-12 slides using the template “Movie Character Presentation.”
2. Provide an introduction and background overview of the movie character (client).
3. Assess the client using the “Functional Health Pattern Assessment.”
4. Based on your “observations” and thoughts, document your assessment, providing examples from the movie.
5. Describe any observed or potential cultural, geographic, religious, ethnic, or spiritual considerations of this client.
6. Describe two normal health patterns of the client as well as two abnormal health patterns that you observe, and provide examples.
7. Develop an appropriate nursing diagnosis for the client based on your assessment.
8. Identify and describe three interventions for the client: health promotion, health prevention, and maintenance.
9. Identify at least two possible resources or community services to which you would refer this client and provide rationale for your choices.
In addition to submitting the presentation to the instructor, post your assignment to the Movie Character Health Assessment Presentation Main Forum as directed by instructor. Respond to other students’ posts in a manner that initiates or contributes to discussion. Each person should make at least three substantive comments.
While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
Compare the physical assessment of a child to that of an adult. In addition to describing the similar/different aspects of the physical assessment, explain how the nurse would offer instruction during the assessment, how communication would be adapted to offer explanations, and what strategies the nurse would use to encourage engagement.
Physical assessment of the child and that of an adult is done similarly yet differently. The act of auscultation, palpation, taking the vital signs to get the objective data are done the same but the normal range limits are different. For example, the healthy adult blood pressure normal range is from 90/60 mmHg – 120/80 mmHg, pulse rate 60-100 beats per minute and temperature of 97.8 ‘F to 98.6″F whereas to a 1-11-year-old child has a heart rate of 70-120 bpm, blood pressure of 90-110 systolic and 55-75 diastolic.
In using Erikson’s theory, an adult’s stage of development is focused on the fear of loneliness if there is no long-lasting relationship and adult contemplates their contribution to society with their achievements or lack of, and for a school-aged child, the focus is more on establishing trust and self-esteem (Grand Canyon University, 2018).
Communication and approach with these two different age groups also differ. A caring and comfortable environment is needed for a school-aged child in order to extend their trust from their parents to the healthcare provider. The questions are also formulated so that the child is able to answer. Whereas for the adult, a more factual and straightforward questioning is done. Utilizing the evidence-based practice tools provided to the health care team, a thorough and effective assessment is done to promote health and have an effective nursing process.
Grand Canyon University (Ed). (2018). Health assessment: Foundations for effective practice. Retrieved from https://lc.gcumedia.com/nrs434vn/health-assessment-foundations-for-effective-practice/v1.1/
Medline Plus. Retrieved from: Vital signs: MedlinePlus Medical Encyclopedia