Comprehensive Assessment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Your Results LLaabb PPaassss
Self-Reflection Activity Time: 20 min
Explicitly describe the
...
Comprehensive Assessment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results LLaabb PPaassss
Self-Reflection Activity Time: 20 min
Explicitly describe the tasks you undertook to complete this exam.
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.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Documentation
Plan My Exam
Self-Reflection
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Auscultation was performed of the patient's abdominal arteries, and bowel sounds. Bowel sounds were
auscultated first starting at the RLQ and moving in a clockwise fashion (RLQ, RUQ, LUQ, LLQ). As were
percussion, and palpation. During the assessment, the patient was told everything that was going to be done
before doing it and was assessed for signs of discomfort.
Upper Extremities: I examined the patient's extremities, first the upper extremities, then the lower extremities.
This included general appearance (skin condition, cuts, scrapes, edema). For the upper extremities, I
examined the patients ROM and strength starting at the shoulders and moving distally to till I reached the
hands. I also assessed peripheral pulses, sensation to soft touch and pain, and hand movements. When at
the hands, I examined the patient's fingernails, checked capillary refill, position sense of a finger,
stereognosis, graphesthesia, and DTRs.
Lower Extremities: Similar to the upper extremities, I examined ROM starting proximally at the hip and moved
distally to the ankles. To do this, the patient was instructed to do the range of motion exercises. During range
of motion, the joints and muscles are palpated, and strength was tested. This can help identify things such as
arthritis, pain, tenderness, swelling, deformity or any other abnormalities. I also assessed peripheral pulses,
sensation to soft touch and pain, and leg movements. When at the feet, I examined the patient's toenails,
checked capillary refills, position sense of random toes, monofilaments, and Deep tendon reflexes.
Body: I examined the patient's spine while standing and her balance. Once the examination was completed I
was open for questions and to call the office if she had any questions or concerns.
Explain the clinical reasoning behind your decisions and tasks.
Student Response: Student Response: I started this exam by first collecting the health history from the
patient, which is subjective data. Subjective data provides insight to the patient and can provide context to
how any current problems may be related. Also, personal data collection helps to guide the physical
assessment and the nursing process. "The nurse's role in collecting subjective data is to use it to improve the
patient's health status and to determine the cause of the patient's current symptoms" (Jensen, 2015). For
example, When asking about Tina's medical history I wanted to know if she had any conditions, and if so
how long has she had them, the severity of any illness, symptoms, aggravating factors, and if she was
currently receiving treatment for it. I also inquired about any allergies, what happens with exposure, the
severity of allergies, and how allergies are/have been treated. Other questions I asked included a social
history, such as if she smokes and for how long. This helps me to identify any personal risk behaviors Tina
may participate in or any environmental risk factors that she may expose herself to.
After conversing with the patient, I started to collect my objective data through physical assessment. Before
performing the physical assessment, I made sure that the patient was comfortable and that her room
temperature was adequate. Also, before starting the nursing comprehensive assessment, I organized my
physical assessment from head to toe, instead of systems. This helps the assessment go more smoothly. For
purposes of explanation, I will do it based on systems. Of note, The physical assessment is done using four
techniques: inspection, palpation, percussion, and auscultation. During the assessment, the patient was told
everything that was going to be done before doing it and was assessed for signs of discomfort. Once the
assessment was complete, I made sure that the patient was comfortable and had everything she needed,
and all of her questions were answered.
Neuro- I asked Tina questions to inquire about any risk factors that she may have of developing a
neurological condition, such as head trauma and any signs or symptoms of neurological or neuromuscular
complications. During subjective data collection an informal neurological assessment was being performed,
such as assessing the patient's speech, alertness, etc.
Obtaining subjective is important because it provides insight to the patient, and to any potential or current
risk factors they may have towards developing or worsening neurological disorders. It also allows for an
informal neurological assessment of LOC, speech, general knowledge, etc. This can be helpful in things like
determining safety hazards/risks, and when providing education. The cerebellar function was tested by
having the patient do a finger-to-nose test and heel-to-shin test. Performing this test not only tests for
possible cerebellar lesions/dysfunction but may also help identify safety hazards (such as being a fall risk, or
needing assistance at home for an unsteady gait). Sensory function was tested to check for sensory deficits,
perception so the patientsclinical situation should be considered when testing it. For example, Tina has
diabetes and is more likely to have the peripheral sensory loss. Peripheral sensory from diabetic neuropathy
is usually distal, whereas someone with the sensory loss caused by spinal trauma will have sensory loss
specific to the area of the skin that is supplied by nerves from the affected spinal root (Jensen, 2015). Testing
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sensory loss can help identify educational points, for example, Tina had a sensory loss on the balls of her
feet, so following up by asking her if she performs daily feet assessments is important (Jensen, 2015).
Respiratory: To assess the patient's respiratory system I asked questions regarding her respiratory status,
and history. By inquiring if she has ever had a respiratory disease, it helps identify the potential for developing
subsequent respiratory conditions. Tina, has asthma, which is a chronic respiratory disease in which the
upper airway is overly sensitive to different environmental stimuli and allergens. This is one reason why I
asked Tina if she had any allergies and what reactions she has had in the past to the allergens. Cats and dust
are two of her allergies that trigger her asthma. I also asked Tina about her lifestyle choices and environment.
For example, I asked her if she has ever used or smoked tobacco, because smoking poses many risks to a
person's health. Smoke inhalation can irritate air passageways, and trigger asthma exacerbations. It can also
lead to other respiratory conditions, such as lung cancer. Asking questions such as these, helps to identify
current and potential risk factors the patient has that can have a negative impact on her health status. It also
helps to identify nursing interventions and education that that can potentially benefit the patient and promote
health. For the objective portion of the examination, I inspected her general appearance and position, noting
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