HEALTH ASSESSMENT/HEALTH PROMOTION PAPER:
1. Identify a chief complaint (i.e. “I don’t hear as well as I used to” or “I have this terrible chest pain”) You can pick any chief complaint that you are interested in exploring more in depth.
2. Discuss what additional subjective and objective data needs to be collected for the chief complaint that you selected. Provide rationale for why it is important to collect that data (this should be referenced with your book or some journal articles)
3. Finish the paper with a discussion of health promotion strategies that should be taught to a client with the “above mentioned” chief complaint. This section should also be referenced with books and/or journals.
4. Page limit: Paper should be no longer than 6 typewritten pages.
5. Paper should use APA format. A minimum of 3 references is required, as well as at least one source for each section (see grading rubric).
6. Grading Criteria:
o Identification of chief complaint: 30 Points
o Discussion of subjective and objective data that needs to be collected 30 Points
o Discussion of health promotion strategies 40 Points
Running head: Health Assessment 1
M.S. is a twenty-one year old, single, African American female, who is currently a full time student at NYU. M.S. came to Advance Medical Clinic with a chief complaint of “I feel itchy on my arms and behind my knees where my rash is”. I will begin my assessment by interviewing my patient to collect subjective data. By collecting subjective data it will provide clues to possible physiologic, psychological, and sociological problems. It will also provide me with information that may reveal my patient’s risk for a potential problem as well as areas of strengths (Jarvis, C.,2008).
Source. M.S. seems reliable.
Reason for Seeking Care. “I feel itchy on my arms and behind my knees where my rash is”.
History of Present Illness. The onset of her chief complaint started “about two weeks ago”. She finds that after she goes swimming, takes a bath or a long shower that her skin becomes more irritable and she scratches more. To alleviate the symptoms she uses lotion that is fragrance free, which sooths the areas that are irritating and itchy. Patient denies using any new laundry detergents, bathing soaps, and hasn’t eaten any new foods within the last three weeks. I also asked M.S if she had any thoughts or opinions as to what her chief complaint might be or what she thinks has caused it. She stated, “my mother and I think that it might be eczema because I had it when I was a kid, but it went away as I got older”.
Childhood Illness. Chicken pox as child when she was in the third grand.
Chronic Illnesses. None
Infection Control History. No exposure to infectious/communicable disease. Patient hasn’t traveled outside of the USA within the past six months. No history of MRSA, VRE or resistant organism.
Obstetric History. Gravid 0/ Para 0/ Abortion 0.
Immunizations. Childhood immunizations are up to date.
Last Examinations. Her last pelvic examination was last year patient states that “everything was normal’. Her last physical was in fall patient stated she tried out for the soccer team at school and needed medical clearance. Last eye exam was done at the time. Patient denies having a EKG.
Allergies. Seasonal allergies to dust and pollen. Food allergies to tree nuts, peanuts, and sesame seeds, soy.
Current Medications. Allegra for her seasonal allergies and an Epipen for food allergies but denies having to use it, and ProAir “for wheezing when I catch a cold”
Family History. Patient states that “my mother has high blood pressure and so does my grandfather, my mother’s father”.
Psychosocial. Denies abuse and neglect. Denies depression, ETOH abuse/substance abuse, lack of social support. Has had no recent changes or losses in her life. Has not used tobacco products in the last year.
REVIEW OF SYSTEMS
General Health. Reports usual health “OK”. She denies recent weight change, fatigue, and weakness.
Skin. “My skin is itchy on my arms and on my legs, and sometimes it bleeds”. Hair: no loss, change in texture. Nails: no change.
Head. No complaint of headaches; no head injury, dizziness, syncope, or vertigo
Eyes. No difficulty with vision. No eye pain, inflammation, discharge, lesions. Wears corrective lenses.
Ears. No hearing loss or difficulty. No earaches, discharge, tinnitus.
Nose. No discharge, sinus pain, nasal obstruction, epistaxis.
Mouth and throat. No mouth pain, bleeding gums, toothache, sores or lesions in mouth, dysphasia, hoarseness, or sore throat.
Neck. No pain, limitation of motion, lumps, or swollen glands.
Respiratory. “I sometimes wheeze when I catch a cold”, no chest pain with breathing; no wheezing or shortness of breath.
Cardiovascular. No chest pain. No palpitation, cyanosis, fatigue, dyspnea with exertion, or orthopnea noted.
The next part of my assessment I will be collecting objective data by performing a physical assessment. I will systematically collect data about the body systems by the use of observation, inspection, auscultation, palpation, and percussion. However, the physical assessment will be adjusted to my patient based on her needs (Jarvis, C.,2008).
Height. 5’7” Weight: 140 lb.
BP: 130/60 mm Hg right arm, sitting
Temp: 98.0, Pulse: 72 bpm, regular; Respirations: 16 per min, unlabored
General Survey. M.S. is a twenty-one year old female, not currently under the influence of alcohol or other drugs, who articulates clearly, ambulates without difficulty, and is in no distress.
Skin. Erythematous papules, edema with serous exudate, weeping, and oozing to bilateral antecubital spaces and to the back of knees on both lower extremities. Hair: normal distribution and texture, no pest inhabitants. Nails: no blubbing, biting, or discolorations. Nail beds: pink and firm with prompt capillary refill.
Head. Normocephalic, no lesions, lumps, scaling, parasites, or tenderness. Face: symmetric, no weakness, no involuntary movements.
Eyes. Acuity by Snellen chart: right eye 20/20; left eye 20/20-1. Visual fields full by confrontation. EOMs intact, no nystagmus, lid lag, discharge, or crusting.
Ears. No mass, lesions, scaling, discharge, or tenderness on palpation.
Nose. No deformities or tenderness to palpation. Nares patent. Mucosa pink, no lesions. Septum midline, no perforation, or sinus tenderness.
Mouth. Mucosa and gingivae pink, no lesions or bleeding. Tonsils 1+. Gag reflex present
Neck. Neck supple with full ROM. Symmetric; no masses, tenderness. Trachea midline. Thyroid nonpalpable, not tender.
Spine and Back. Normal spinal profile; no scoliosis. No tenderness over spines; no CVA tenderness.
Thorax and Lungs. Chest expansion symmetric. Breath sound clear bilaterally, non labored.
Breasts. Symmetric; no retraction, discharge, or lesions.
Heart. Precordium: no abnormal pulsations, no heaves. Heart rhythm regular, no pacemaker, stents, or internal defibrillator. No edema noted
Abdomen. Flat, soft and symmetric. Bowel sounds present. Last bowel elimination 9/18/12.
Extremities. Moves all extremities to command. Moves bilateral extremities equally.
Musculoskeletal. Able to maintain flexion against resistance and without tenderness.
Neurologic. Alert and oriented to person, place, time and situation. Calm and cooperative.
HEALTH PROMOTION STRATEGIES
My patient has impaired skin integrity related to dermatitis. Defining characteristics of dermatitis is inflammation, dry/flaky skin, erosions, excoriations, fissures, pruritus, pain and blisters. An expected outcome is that she will maintain optimal skin integrity within limits of the condition, as evidence by intact skin. To assist my patient with this goal I would suspect that the physician will refer her to a dermatologist.
M.S. is also at risk for infection related to impaired skin integrity, inflammation, and excoriation. An expected outcome would be that she remains free of secondary infection. To aid with this goal I would expect the physician to prescribe a topical antibiotic.
Another common related factor is disturbed body image related to visible skin lesions. My goal for M.S. is that she will verbalize feelings about dermatitis and continue daily activities and social interactions.
Other therapeutic interventions that I will recommend are the following:
Continue using fragrance free detergents, soaps, and lotions.
Stay away from food allergens.
Moisturize skin several times a day.
Use look warm water for bathing, avoid baths and try to take short showers 3min or less, avoid excessive bathing and apply moisturizers while still damp.
After swimming rinse off with water to remove chlorine.
Limit exposure to anything irritating to the skin.
Use a cold compress to curb the itch and keep fingernails short.
Double rinse clothes that you wash or prewash new clothes before wearing.
Reduce stress (Peate, I., 2011).
Jarvis, C. (2008). Physical examination & health assessment (6th ed.). St. Louis, Mo.: Saunders/Elsevier.
Peate, I. (2011). Eczema: causes, symptoms and treatment in the community. British Journal of Community Nursing, 16(7), 324-331. Retrieved September 17, 2012, from the CINAHL database.
Purdue OWL: APA Formatting and Style Guide . (n.d.). Welcome to the Purdue University Online Writing Lab (OWL). Retrieved September 17, 2012, from http://owl.english.purdue.edu/owl/resource/560/01/