The Health Assessment Essay

Write a detailed one-page narrative (not a formal paper) explaining the health assessment information required for a diagnosis of your selected patient (include the scenario number).

Explain how you would respond to the scenario as an advanced practice nurse using evidence-based practice guidelines and applying ethical considerations. The Health Assessment Essay

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Justify your response using at least three different references from current evidence-based literature (last 5 years).

CASE STUDY 4
A single mother has accompanied her two daughters, aged 15 and 13, to a women’s health clinic and has requested that the girls receive a pelvic examination and be put on birth control. The girls have consented to the exam but seem unsettled. The Health Assessment Essay

Write a detailed one-page narrative (not a formal paper) explaining the health assessment information required for a diagnosis of your selected patient (include the scenario number).
Explain how you would respond to the scenario as an advanced practice nurse using evidence-based practice guidelines and applying ethical considerations.
Justify your response using at least three different references from current evidence-based literature (last 5 years).
.
. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. The Health Assessment Essay

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. The Health Assessment Essay

Definition and components of health assessment
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 Health Assessment Essay

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. The Health Assessment Essay

Purpose of health assessment
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. The Health Assessment Essay

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. The Health Assessment Essay

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. The Health Assessment Essay

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).

Health assessment in various settings
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. The Health Assessment Essay

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. The Health Assessment Essay

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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.

Conclusion
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 use d in making clinical judgments as well as guiding nursing care. The Health Assessment Essay

Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that…show more content…
Stopped after 6 months because of drowsiness.
1990: Diagnosed with peptic ulcer disease, which resolved after three months on cimetidine. She describes no history of cancer, lung disease or previous heart disease.
Allergy: Penicillin; experienced rash and hives in 1985.
Social History
Alcohol use: 1 or 2 beers each weekend; 1 glass of wine once a week with dinner. The Health Assessment Essay
Tobacco use: None.
Medications: No prescription or illegal drug use. Occasional OTC ibuprofen (Advil) for headache (QOD).
Accidents or Injuries: No automobile accident.
Immunizations: Childhood immunizations up to date. Last influenza, “probably 2 years ago”. No TB skin test.
Last Examinations: Last examination 2 weeks ago, general check up, told “normal”. Yearly clinical breast examination (CBE), mammography, told “normal”. Yearly Pap smear, last performed January last year, 2010. Last visit to oncologist, 2008, told “normal”. The Health Assessment Essay

On admission to a healthcare facility, a health assessment is a mandatory tool in assessing the patient’s health status. In general an assessment is broken down in a two types of reviews, by conducting a health history which includes the collection of subjective data (information elicited by the patient or patients family members) and a physical examination of the patient which includes the gathering of evidence based data (Wilson & Giddens, 2009). Collecting and documenting accurate information is imperative in providing the allied health team this information to facilitate an efficient and well-formed care plan, as well establishing a baseline for subsequent assessments (Springhouse, 2004; Wilson & Giddens, 2009). The Health Assessment Essay