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NURSING > SHADOW HEALTH > Comprehensive Assessment | self reflection .pdf (All)

Comprehensive Assessment | self reflection .pdf

Document Content and Description Below

Student Response: A comprehensive assessment is a complete, all-encompassing, in-depth assessment that includes a complete health history and physical assessment. Components of the health history are the patient's personal history of illness, as well as their family medical history, including any current or prior treatments, surgeries, risk factors, and medications or supplements. In addition, it should include details of other aspects of health, such as the patient’s perception of their health, health beliefs, coping mechanisms, support systems, and functional status. The ﬁrst question I asked was for Tina to verify her name and date of birth. This is a safety check that assures the assessment I am about to conduct, is on the right patient. It also helps me to determine if this patient is alert to self. Another important question that I started my interview process with was asking the patient the reason for her visit, and if she had any health concerns she would like to discuss. This helps focus the attention on the patient and what he or she needs or hopes to get out of the visit, and also helps guide the interview. Other questions were based on the components of the health history mentioned earlier. For example, I asked Tina how she felt she was doing, to get insight to her perception of health, which can help identify areas of that Tina may need further education on. In addition, I asked Tina what her medical history was, what (if any) medications (OTC, prescribed or supplements) she was currently taking and the reason for taking them, and the dose and frequency. Aside from Tina’s health I asked questions about her personal life, such as who she lived with, what her new job would be, relationship status, and what she enjoyed doing for fun. Again, helping to develop a relationship with the patient, but also providing me with insight to her functional status, support systems, and so on. Other questions asked pertained to risk factors or unhealthy/unsafe behaviors. For example, asking Tina is she currently smoked, or used illicit drugs, or had unprotected sex helps determine if she partakes in unhealthy/unsafe behaviors. Once subjective data was collected, I performed the comprehensive physical assessment, which according to Jensen (2015) should be a complete head-to-toe examination. Head/Neck: I examined the patients head/face for general appearance, symmetry, expression, etc. I assessed her skin, hair, and scalp. I estimated her eyes for equality, pupil response, eye movements, and vision; her ears, nose, mouth, and throat. I palpated her lymph nodes and carotids. I tested her neck strength and ROM. Chest: I examined the patient's chest, in the following sequence, ﬁrst anteriorly, then posteriorly. First I inspected the pt position and appearance, to see if the patient appeared comfortable. Noting for any signs of respiratory distress. Then I examined the patient's chest for symmetry, size, shape, and muscle use. Next, I auscultated the patient's heart and lung sounds. After auscultation, I palpated PMI, and tactile fremitus anteriorly, and palpated posteriorly for tactile fremitus, symmetry, and expansion and palpated for CVA tenderness; Last, I percussed all lung ﬁelds. Abdomen: I examined the patient's abdomen in the following order: inspection, auscultation, percussion, and palpation to include the general appearance of ( scars, masses striae, etc.) symmetry, shape, and size.

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