41935_Fetelika_Thomas_Malaefono_Health_Assessment_694065_1074204035

Health Assessment as a Crucial Factor in Nursing FieldThe World Health Organization (WHO, 1999) reported that health assessment is the activity of gathering data, so as to quantify the illness and distinguish the fundamental necessities that calls for prompt reaction in the repercussions of a catastrophe. Therefore, it basically means that it is a collection of data of a patient’s health where nurses documents and retrieves assessment data interacting or working together with other health professionals (Weber & Kelley, 2013). This is supported by Jarvis (2011) as stated that it exists as a variety of information of a client’s condition determining which evaluation facts should be self-possessed, hence, its role is being crucial to nursing practice by practising and growing the know-how and skills of fitness evaluation you may expand self-belief and competence in gathering information and responding to every person’s state of affairs (Forbes & Watt, 2015). This is supported by Jarvis (2011) stating that the assessment is an unfathomably profitable instrument for accumulation of abilities. This assessment enables you to identify the illness of the patient, how the side effects are created, and a procedure to find any related physical discoveries that will help in the advancement of differential analysis CITATION Jar11 t l 2057 (Jarvis, 2011). This skill is initiated when the dualistic foremost mechanisms of the assessment included as follows, physical evaluation and health history, where it uses subjective and objective data; hence, the subjective assessment aspects being testified by the client, whilst the objective assessment data contains that which is visible and assessable. Physical assessment involves the examination of the body regarding the physical state of the person. Alternatively, health history involves the keepings of the health records of the client and the families CITATION Jar11 t l 2057 (Jarvis, 2011). This enables nurse to attain the necessary information to document and analyze them for future references of the patient’s health history CITATION Jar11 t l 2057 (Jarvis, 2011). It enables the nurse to perform a focused assessment in order to formulate and develop a comprehensive care plan for the patient, identifying the strengths and downfall of the patient, that is, what the capability and ability of the patient CITATION Web13 l 2057 (Weber & Kelley, 2013). Henceforth, the prospect of the this assessment is to identify the characteristics of evidence-based practice, diagnostic reasoning of analyzing data with its process and critical thinking based on the patient’s health status CITATION Jar15 t l 2057 (Jarvis, 2015). Traditionally, students were skilled to use this assessment on patients with the review of systems in mind, as its purpose of is to ask precise, often closed-ended, questions that allows you to help make an analysis in order to identify and obtain information that can be used to develop a nursing care plan for the patient. Unfortunately, this approach frequently led to an incomplete and/or misguided database and restricted the ability of the interviewer to establish rapport with the affected person. Patient-targeted interviewing specializes in the personal and emotional context and encourages the patient to spontaneously describe his or her signs and symptoms CITATION Mar12 l 2057 (Mark C. Henderson, 2012). Moving on, the Health Assessment as mentioned plays a crucial role in the ward or in clinics with the roles of nurses at its frontline. Firstly, amongst the many responsibilities nurses burden themselves within a health care scene; it is also the nurses’ duty to obtain accurate data from the patient. Thus this contributes to the enhancing of the nursing intervention offered to the patient, convincing the patient that you will provide all the care they need. In an interviewing process, it is the nurses to ensure that the patient is in a comfortable, private, and well ventilated area. This enhances a more possibility for the patient to describe and give more information to the nurse without any hesitations. The approaching behaviour of the nurse to the interviewing scene is important as it establishes the foundation of the interview. Here, the nurse can be seen as an interviewer too. This individual nurse sets a very suitable atmosphere for the patient to perceive accurate data from the patient. Thus it includes values such as respect, acceptance and a non judgmental approach. With these values and a welcoming approach, it affects the patient’s eagerness to adhere to the nurse and co-operate appropriately. For instance, a moody patient will not present all the required information, therefore, the nurse may tend to foster a safe atmosphere whereby the client may have turned against his or her mood and co-operate again with the nurse. In addition, the bio-data was obtained to identify present health conditions, symptoms and other relevant information. In this case, Mr Reddy Singh, born on the 5th of May,1971, age 48, an Indo-Fijian and a Christian by faith, originated from Ba Village and residing at Nakasi; Valelevu Rd and can be contacted via phone 8733039, or via Gmail at [email protected] as contact sources. His occupational level states as a senior engineer at the Fiji Sugar Co-operation company. His current marital status state as a married man with his spouse Mrs Kajal Reddy with two children. This information was obtained from the client in his full level of consciousness as he is fully alerted and oriented to time, place and situation. Moreover, Mr Reddy arrived on the 26th of June with his chief complains of head ache and fever that he has been experiencing for the past three (3) days. He expressed that the pain was at the posterior end of the head as the location of the pain was on the temporal lobe. This affected his diet as he seldomly eats and sleep due to his depression as stated by him. The duration as stated before was for 3 days and was continuously in pain as it affected his daily work. For the character of pain, he stated that it was getting worst each day, that he could not with the pain making him decided to visit the hospital, as he described the severity of pain as 7-8 from pain scale of 1 to 10. As for the aggravating factors included was his work in the plantation all day under the hot sun and drinking of kava or grog session that kept him awake at nights which worsen his headache. However, he would apply a damp cloth when sleeping to reduce the fever and take up Panadol to relive the pain. As for the symptoms that was shown included emotional distress and dry eyes due to insomnia. As a father, this affected his work to provide for his family. This leads to increase of stress level as it aggravates the pain from his neck muscles and a pulsation on his temporal lobe. Beside this, other associating factors included were the financial issues and social issues with his workmates at times that affected his cognitive thinking and his headache. He also stated that his headache happens when he is working in the plantation or when he is drinking kava at times, and the pain usually lasts for 5 hours or less. Moving on, his health was also taken into records when interviewed. According to the patient, for chrome illness, he only had sunburn due to his work in the plantation but nil allergies. His childhood illness as he stated was that he was physically fit with nil fatigue compared to his current state. His teenage years, however, he had an accident in the plantation where he slipped and dislocated his left knee and was hospitalized for two days at the Labasa Health Centre. He also stated that he had nil operations and surgery, however, his left knee was only relocated and was As for his family history, there was nil chronic disorder within the family. In addition, from his parent’s perspective and history, Mr Reddy’s mother has nil chronic infection. Likewise, his father’s side, but, Mr Reddy’s oldest aunty, his father’s eldest sister had history with high blood pressure, but without any diagnostic of chronic disorder. Furthermore, he stated that his parent are still alive and well, however, his grandparents had died of old age, his grandmother at age 78 and grandfather at age 80. Other than that, his aunty with a history of high blood pressure is also alive.Moving on, during the exam of the review of systems from head to toe, also known as physical examination, it permits the attendants to asses and can determine whichever bodily trace which could result in any interaction with infection. It additionally assists in the assessment of the past and current well-being of every single information about the patient, to review twice in circumstance where some information’s might be left-out (Forbes & Watt, 2015). This review of systems will be based on Jarvis findings (2011). For the general constitutional system, Mr Reddy stated that he had headache and fever, with insomnia and weight loss and fatigue for the past two days. His mental status as stated by the patient was that he experienced depression, difficulty in concentration and sleepless night at times. In addition to skin, hair and nails, he has a scar on his left knee from his accident in his younger age with additional pain during cold weather. He also stated that his hair began to turn grey at age 43, due to his growing age and also a factor of his stress level may contribute to this. Other than that, nil itching pigmentation, nil abnormal nail growth and nil nail fungus and he always keep his nails short making his work easier in the plantation. He expressed that he has frequent headaches and dizziness when working in the sun, but nil concussion and nil periods of loss of consciousness. At times, he expressed that he experiences blurring and changes in appearance or vision, likewise, photophobia, and he usually wets his face when he eyes are dried up as he experiences pain, however, nil history of eye trauma. Upon listening, he has nil hearing loss, nil pain, nil discharge or infection as stated by him when he went for his hearing exam a week ago. According to him, his sense of smell is working appropriately with nil obstruction, nil discharge, and nil sinus pain. In reference to throat and mouth, he had nil inflammation of gums, nil extractions, nil change in voice and nil sore throat, however, he experienced a disturbance of taste as he had a loss of appetite from his fever. He also stated that he had nil enlargement, nil tenderness and nil suppuration in respect to his lymphatic systems. Adding on, in respect to his chest and lungs, nil pain related to respiration was experienced by the patient as stated by Mr Reddy, likewise, nil dyspnoea, nil cyanosis, nil wheezing or coughing and nil sputum present. For breast inspection, when interviewed, he stated that he had nil development of pain, nil tenderness, likewise, nil galactorrhea, nil discharge and nil lumps. As For his heart condition, he indicated that he had nil chest pain or distress, nil dyspnoea and orthopnoea, and nil coronary artery disease present. Analyzing his blood vessels and peripheral vascular, his statement was that he had nil edema, nil claudication, nil thrombosis or thrombophlebitis, however, his hands gets numb at cold season. For his gastrointestinal tract, he expressed that he has a loss of appetite due to fever, other than that, nil dysphagia, nil vomiting, he can ingest well and nil history of abdominal diseases and flatulence, and also nil constipation and diarrhoea when visiting the toilet. Alternatively, for his urinary tract, he stated that when voiding he experienced a sting or burns due to fever. He urinates twice a day. He stated that the urine colour was normal, and included that there were nil polyuria or oliguria, nil dysuria and nil urinary disease presents. In respect to his genital system, he only stated that he has nil STD. In terms of his musculoskeletal, he expressed that the only join stiffness and pain he experiences is on his left knee during cold season, other than that, there were nil swelling, nil redness and nil deformity present. His range of movements, however, is fully moveable. To the least of the systems, in regarding to his neurological system, he expressed that he has nil seizure or paralysis, nil sensation or coordination, nil loss of memory and nil tremors were present. This finalises his level of consciousness to be fully alerted.Moving on to functional health patterns, this provides the format of the ability of daily activities done with or without assistance. In this case, Mr Reddy stated that he is normally healthy and well. According him, he generally works in his plantation time to time in the weekends. He sleeps regularly from 7-8hours of sleep to analyzing in his enjoyment instances unless his on his grog session with workmates. His diet is always balanced and normally taken every meal as he does not have any food allergies. As regards to his non-public behaviour, he smokes suki simplest and consumes yaqona generally. He spends few times with his families as most of the time he is in the plantation or working at the company. He also stated that he does not engaged in illegal drugs. Upon the fulfilment of such evaluation on Mr Reddy, the attendant had the option to examine and outline the issue rundown of the client and will probably develop a nursing care plan. Referring to the information obtain from Mr Reddy, the nurse should make arrangement. The nursing care plan is done according to NANDA’s format are as follow (NANDA, 2019):The assessment of the nursing care plan was identified – headache and fever. The nursing diagnosis was as stated – headache due to stress level and less sleep; fever of 40*C caused due to headache. In addition, the nursing plan included were; to reduce temperature within an hour and reduce headache and fever. The intervention – to decrease the temperature by sponging with damp cloth and follow up with medication prescribed by his doctor to relieve his headache.The evaluation – temperature reduce from 40*C to 37*C and to relieve his headache and fever.To conclude, physical examination and health assessment are vital diagnostic tool that enables nurses to keep track of any changes taking place in the patient’s body that may be indicative to an underlying disease or condition. Without regular check-ups, those conditions can go undetected. A complete physical examination includes the evaluation of general patient’s appearance and the review of systems. It is also important in understanding patients’ health condition as shown in the case of Mr Reddy Singh.  MR REDDY’S GENOGRAM:128905027178000 Grandma (died age 78) Grandpa (died age 80246761023622000)17475201003300017151351765300020313651962150032219908350900322199083185004901609297844003041650255905005067935927100018567409525002320925308610002275205157480002615565952500Mom (age 72) Father (age 76) Aunty (age 69)238252025844500 Mr Reddy 48-year-old (Headache and fever) KEY: 13081019431000 – Female 33528021971000-32004021971000 Or – Hypertension11557018986500 -Male191770184150019177011112500 -Married ReferencesForbes, H., & Watt, E. (2015). Jarvis’s Physical Examination and Health Assessment (2nd Ed.). Australia: Elsevier.NANDA. (2019) Headaches Nursing Care Plan Interventions. Retrieved 16 September 2019,from https://nurses-nanda.blogspot.com/2012/03/headaches-nursing-care-plan.htmlJarvis, C. (2011). Physical Examination and Health Assessment (6th Edition ed.). St. Louis: Elsevier Saunders.Mark C. Henderson, L. M. (2012). The Patient History: An Evidence-Based Approach to Differential Diagnosis (2nd edition ed.). New York: McGraw-Hill.Weber, J. R., & Kelley, J. H. (2013). Health Assessment in Nursing (5th Edition ed.). Philadephia: Lippincott Williams & Wilkins.World Health Organization. (1999). EMERGENCY HEALTH TRAINING PROGRAMME FOR AFRICA [EBook]. Addis Ababa. Retrieved from http://apps.who.int/disasters/repo/5509.pdf