Health assess 3425 Week1 graded

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General status, vital signs, pain and nutrition
Name___Kayla Kristen Smith_____________
Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions

Findings

Current Status
1. Allergies
2. Present health concerns

No known allergies
Reports concern of high blood pressure

Past History
3. Recent weight gains or losses?
4. Previous high fevers, cause, and treatment?
5. History of abnormal pulse?
6. History of abnormal respiratory rate or character?
7. Usual blood pressure, who checked it last, and when?
8. History of pain and treatment?

Recent gain of 10 lbs
Patient denies
Patient denies
Patient denies
120/70, Blood drive
December 2014
Childhood and adolescent ear infections treated with antibiotics Family History
9. Hypertension?
10. Metabolic/growth problems?
Pain

11. Pain (using COLDSPA)

Patient denies
Has overcome adolescent morbid obesity (Everyone has had pain at some time or other-if your patient is healthy and currently pain-free, you may need to use a past instance of pain.)
Generalized
aching/throbbing in right greater iliac

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Character: how does it feel—what sort of pain is it?

region. “It just hurts”

12. Onset:

With running long distance. 13. Location:

Right hip pain radiates to back

14. Duration:

Intensifies with running subsides after several hours of rest from exercise.
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15. Severity (scale of 1 – 10):

16. Pattern—what makes it better or worse:

Pain intensifies with jogging. Subsides with rest.
Patient denies.

17.Associated factors—does it cause you to have other symptoms too?

18. How does pain impact the other areas of life?

2.What are your concerns about the pain’s effect on
a. general activity?
Denies concern.
Patient mentions he “just doesn’t get to work out as much or long as I want to”
b. mood/emotions?
“It is irritating”.
Denies further

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c. concentration?
Patient denies.
d. physical ability?
Admits a decrease in ability to jog for cardio exercise. e. work?
Patient denies.
f. relations with other people?
Patient denies.
g. sleep?
Patient denies.
h. appetite?
Patient denies.
i. enjoyment of life? Patient denies. Objective data (General status and vital signs, pain and nutrition)
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, used with permission.
Questions

Findings

Current Status
1. Observe physical development (i.e., appears to be chronologic age).

Height, stature and build appear to become consistent with chronological

4 age. 2. Observe skin (i.e., general overall color, color variation, and condition).

3. Observe dress (occasion and weather appropriate). 4. Observe hygiene (cleanliness, odor, grooming). 5. Observe posture (i.e., erect and comfortable) and gait (i.e.,rhythmic and coordinated).

6. Observe general body build (muscle mass and fat distribution).

7. Observe consciousness level
(alertness, orientation, appropriateness). 8. Observe comfort level-does patient exhibit visible signs of pain?

9. Observe behavior (body movements, affect, cooperativeness, purposefulness, and appropriateness). Skin tone is even with no evidence of vascular or pupuric lesions. a tan color.
Skin is smooth and even. Skin rebounds and does not remain indented when pressure is released No edema, cyanosis, or clubbing present in the upper or lower extremities. No blanching seen in fingernails or toenails, pink tone returns immediately to nails in less that 2 seconds when pressure is released.
Dress is appropriate for the situation and weather. Appears to be well-groomed and clean.
Well shaven. Kempt appearance. No presence of malodor on patient.
Posture is erect and relaxed. Gait is rhythmic and coordinated with purposeful movements. Full strength present. No visible deformities. Muscles are bilaterally equivalent in strength.
No visible deformities. Muscles are bilaterally firm and well-developed. Arm and leg musculature are equal in appearance with no obvious deformities.
Fat and muscle distribution are evenly distributed. Patient is alert and oriented to time, place, self, and situation. Able to respond appropriately to conversation and questions. Patient obeys commands.
Patient does not display any obvious signs of pain.

Patient affect is responsive and no blunted. Easily expresses emotional and is cooperative with questions.
Movements are relaxed and purposeful.
Behavior is appropriate for situation.

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10. Observe facial expression (cultureappropriate eye contact and facial expression). 11. Observe speech (pattern and style).

Client smiles with relaxed and appropriate facial expressions. Client maintains eye contact. Client displays a full Range of Motion with no presence of guarding or tension.
Speech is clear and pattern is moderately paced. Vital Signs
98.9 F

12. Temperature
13. Heart rate (pulse-- rhythm, amplitude)
14. Respirations (rate, rhythm, and depth). 15. Blood pressure

58
16-18 breaths per minute. Inspirations are shallow and nonlabored with no adventitious lung sounds. Bilateral chest expansion are symmetrical with each breath. 118/68.

Nutritional assessment: Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions
Current Status
1. Type of diet (for instance, low carb, vegetarian, diabetic, etc.) 2. Appetite changes
3. Weight changes in last 6 months?
4. Problems with indigestion, heartburn, bloating, gas? 5. Constipation or diarrhea? Findings
Low carb diet.

Denies appetite changes.
Gain of 10 pounds in the past 6 months
Patient denies.

Patient denies.

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6. Dental problems?
7. Conditions/diseases affecting intake or absorption, i.e., irritable bowel disease, gluten sensitivities, etc.,?
8. Frequency of dieting? Patient denies.
Patient denies.

Patient denies dieting. States he does not believe in dieting but does try to restrict the amount of “carbs I eat”.

Family History
9. Chronic diseases?
10. Weight issues?

Maternal Grandmother breast cancer.
History of adolescent morbid obesity.

Lifestyle and Health
Practices
11. Average daily food intake—how many meals and snacks?
12. Approximately how many 8-oz. glasses of fluid per day are consumed? 13. Type of beverages consumed? 14. Dine alone or with others? 15. Frequency of eating out? 16. Do long work hours affect diet?
17. Sufficient income for food? 18. List a 24 hour recall of food intake.

3 meals per day. 3-5 snacks per day.

Patient reports 10-12 glasses per day.

Reports mainly consumes water and 1-2 cups of coffee per day.
Reports that he dines with family at breakfast and dinner.
1/ per day.
Patient reports stress from work affecting his desire to take the time and plan healthy meals when he gets off work. Reports extreme fatigue after work.
Patient states income is sufficient to cover grocery bills.
On 4/10 at 1300: Chilies cheesy fries and pulled pork tacos 4/10 at 2100: left over pulled pork taco
4/11: 0700 Banana
4/11 @ 1300: ice cream and a diet coke.
4/11 @ 2100: ribs and sausage with mashed potatoes.

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19. How many alcoholic drinks per week are consumed? Reports intake of 6 beers per week

Objective data: Nutrition assessment
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions

Findings

Current Status
1. Measure height.
2. Measure weight (1 kg = 2.205 lb).
3. Determine BODY MASS INDEX (BMI = weight in kilograms/height in meters squared or use the NIH website: http//nhlbisupport.com/bmi/bmicalc.htm) . Compare results to BMI in Table 13-3, on in the textbook. To which category does your assessment partner belong?
4. Measure waist circumference and compare findings to Table 13-5 in the textbook. Which category of risk captures this person’s situation?

6’0”
88.435
BMI: 26.4
Category: Overweight range

Waist circumference: 36.5
Risk category: at risk

SBAR
Read the instructions and rubric on the assignment form before completing this.
As you have assessed your patient, which finding from the “General Status, Pain,
Nutrition and Vital Signs” assessment would require attention from the clinician (if it is sufficiently serious to warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle problem? Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing that he/she gets insufficient exercise, is obese, or doesn’t eat a balanced diet—perhaps not as many fruits or veggies as recommended. Most people don’t drink enough water—you can often use that if nothing more serious is apparent. If your assessment partner has chronic health problems or pain, address one of those problems below.
SBAR

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Situation

Background
Assessment
(Name the problem)
Recommendation

Patient meals consist of low nutrient and high fat content. Patient has a history of weight control issues and morbid obesity in adolescence. Currently struggling to maintain a healthy consistent diet.
Patient reports stress and fatigue at work affecting his choices of healthy meal planning. Lack of adequate sleep and poor dietary intake.
Recommend that the patient follow up with nutritionist or primary physician to draw cholesterol levels and possibly look into sleep study to investigate further into patient feeling extremely fatigued after 6-7 hours of sleep per night. Recommend patient to get weekly cardio exercise of 1 hour 3 times/week. Also recommend patient to spend time at least 1 hour per week planning grocery trips that consist of patient buying ingredients to cook quick easy healthy meals.