Health Assessment Essay Example
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.Health Assessment Essay Example
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?Health Assessment Essay Example
With regard to the case study you were assigned:
· consider the insights they provide about the case study.
· Consider what history would be necessary to collect from the patient in the case study you were assigned.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Health assessment plays an important role in nursing. It guides nursing diagnosis and care provided to patients (Fulton, Lyon, & Goudreau, 2014). The aim of this essay will be to define health assessment, outline some of its major components and discuss the purposes of health assessment from a nursing perspective. Besides doing this, the essay will provide two examples outlining the manner in which health assessment can be conducted in two different set ups. The first part starts by defining health assessment and describing its two major components. The second part discusses the purpose of health assessment whereas the third part outlines how the exercise can be conducted in two different situations. Health Assessment Essay Example
In nursing, health assessment may be defined as a logical, deliberative as well as interactive process through which nurses collect, document and synthesize information from clients (Fulton, Lyon, & Goudreau, 2014). Clients in this case may be patients or other people that may not necessarily be sick, but they may be interested in having their health conditions evaluated by nurses. The purpose of this exercise is to make clinical judgments based on the information that nurses collect from clients (Wilson, & Giddens, 2014). Given the diversity of medical conditions, nurses in different units conduct different types of health assessments. Based on this fact, those in cardiac care unit are likely to be familiar with cardiac issues whereas those in neurologic unit are likely to be familiar with neurologic issues. While this is the case, those in advanced practice might play extended roles than those in other levels.
The two main components of health assessment are physical assessment and health history. Physical assessment may be classified into three different categories. First, it may be classified as complete assessment that involves examination of every part of the body. Second, it may be classified as examination of a particular part of the body when that part experiences a problem. In contrast to complete assessment, this type of assessment involves examining the ailing part of the body such as limb when one is not able to walk. Third, it may be classified as examination of a body system. This type of assessment in contrast to other types involves examining a particular system of the body such as cardiovascular system. The aim of physical examination is to obtain baseline data that can be used to establish the functional abilities of a client, supplement client’s medical history as well as form the basis of diagnosis or care among other aims (Weber, & Kelley, 2013). Health history, on the other hand, involves looking at the health record of a client as well as health record of the family of the client. This enables a nurse to evaluate whether the current medical condition of a client has any relationship with his/her health history or that of his/her family.Health Assessment Essay Example
From a nursing perspective, health assessment plays a number of important roles in nursing. Some of these roles include the following. First, it helps nurses to collect, document as well as analyze information from clients (Fulton, Lyon, & Goudreau, 2014). In this case, the moment patients visit hospitals or nursing homes they find nurses that evaluate their medical conditions and collect vital information relating to those conditions. That information is documented and analyzed to guide the type of care and intervention offered to patients. Second, once this information is collected from patients, it is used to make clinical conclusions or judgments that are used to care for patients. In this respect, health assessment is an important aspect in nursing.
Third, health assessment helps nurses to identify the strengths and weaknesses of their clients. In particular, it enables nurses to understand what their clients can do or not do on their own. By so doing, it helps nurses to make good judgments regarding the type of care or intervention that should be offered to different patients. Fourth, it also helps nurses to identify the needs of their clients (Fulton, Lyon, & Goudreau, 2014). In this case, some patients might not understand their health needs because of their medical conditions or ages. In such cases, nurses through health assessment are able to identify the medical conditions of patients and the right intervention for those patients.Health Assessment Essay Example
Fifth, health assessment is used to supplement and confirm some aspects that might not be outright from the outlook. For example, examining the way a patient feels about an ailing part of the body might be used to confirm what the nurse knows about a condition. This in return might improve care in nursing. It might also ensure that the right intervention is offered to the patient (Weber, & Kelley, 2013). Sixth, health assessment is used in nursing diagnosis and providing care to patients. In nursing diagnosis, it is used to guide clinical judgments whereas in providing care it is used to determine the type of care that should be offered to a patient.
Seventh, health assessment is used to identify areas that might require health promotion as well as what might be done to improve health. For example, upon examining a patient a nurse might be in a position to advise that patient what he/she can do to improve his/her health status. In some instances, health assessment might be used to determine the physiological outcome of a health care in nursing so that nursing care can be improved (Kvas, Seljak, & Stare, 2014).
Different settings may require different approaches. However, this does not mean that the process of assessing patients changes in any way. It only means that the manner in which it is conducted might change slightly depending on the age or medical condition of a client. In order to demonstrate this point, I will evaluate two different set ups. The first set up involves a child in a community setting whereas the second set up involves an elderly person in an aged care facility.Health Assessment Essay Example
Starting with a child in a community setting, it would be important to acknowledge the fact that the child might not be able to give credible information despite being able to express what he/she feels. At the same time, the child might not be able to communicate. For this reason, the nurse will be responsible for conducting most part of the assessment rather than relying on the child or his/her parents to provide information. Assuming that the child is not able to communicate, a nurse might conduct health assessment on the child by asking the parent of the child a few questions. Such questions might relate to fever or the way the child behaves. More specific questions might include whether the child has been vomiting or behaving strangely. Once the nurse obtains this information from the child’s parent, the nurse might conduct a physical examination on the child. In this case, the nurse might start by checking the body temperature of the child (Habich, & Letizia, 2015). After doing this, the nurse might conduct head-to-toe examination on the child to check for vital signs that might lead to a particular clinical conclusion. If need be, the nurse might inquire into child’s health history.
In contrast to the first set up, an elderly person in an aged care facility might be able to communicate. Accordingly, health assessment will be directed by information originating from the elderly person. In this case, the nurse may not necessarily conduct a head-to-toe examination on the elderly person because the person would be able to express himself/herself (Fulton, Lyon, & Goudreau, 2014). Instead, the nurse may examine the ailing part of body and provide care as per the condition of that part of the body as well as the way the elderly person may be feeling.
Health assessment as evaluated in this essay plays important roles in nursing. It helps nurses to identify what patients can do or not do on their own. It also enables nurses to identify the needs for patients and what can be done to improve the health status of patients. In so doing, nurses are able to provide efficient care to patients. Apart from this, health assessment is used to confirm as well as supplement what nurses already know about a medical condition. It is also used to determine the physiological outcomes of a possible health care thereby ensure nurses provide efficient care to patients. Above all, health assessment is used in making clinical judgments as well as guiding nursing care.Health Assessment Essay Example
Fulton, J., Lyon, B., & Goudreau, K. (2014). Foundations of clinical nurse specialist practice. New York: Springer publishing company.
Habich, M., & Letizia, M. (2015). Pediatric pain assessment in the emergency department: a nursing evidence-based practice protocol. Pediatric nursing, 41(4), 198-202.
Kvas, A., Seljak, J., & Stare, J. (2014). Training needs assessment for leaders in nursing based comparison of competency models. Organizacija, 47(1), 66-75.
Weber, J., & Kelley, J. (2013). Health assessment in nursing. Baltimore: Lippincott Williams & Wilkins.
Wilson, S., & Giddens, J. (2014). Health Assessment for Nursing Practice. London: Elsevier Health Sciences.
Health Assessment Essay Example