NRS-434V Week 5 Benchmark: Individual Client Health History And Examination

Health Assessment – The Health Assessment of Infants

re conducted in a comparable yet separate manner. The act of auscultation, palpation, and vital sign taking to obtain objective data is the same, but the normal range boundaries vary. A healthy adult’s typical blood pressure range is 90/60 mmHg – 120/80 mmHg, pulse rate 60-100 beats per minute, and temperature 97.8’F to 98.6’F, but a 1-11-year-old child’s heart rate is 70-120 bpm, blood pressure is 90-110 systolic and 55-75 diastolic, and temperature is 97.8’F to 98.6′

An adult’s stage of development, according to Erikson’s theory, is focused on the fear of loneliness if no long-term relationship exists, and an adult considers their contribution to society with their achievements or lack thereof, whereas a school-aged child’s stage of development is focused on establishing trust and self-esteem (Grand Canyon University, 2018).

Communication and approaches with these two age groups differ as well. A loving and pleasant environment is required for the parents of a school-aged child to place their trust in the healthcare professional. The questions are also written in such a way that the child can respond. The adult, on the other hand, is asked more direct and factual questions. To improve health and have a successful nursing process, a thorough and effective evaluation is performed using the evidence-based practice tools made available to the health care team.

Grand Canyon University

In this assignment, you will be completing a health assessment on an older adult. To complete this assignment, do the following:

1. . Students who do not work in an acute setting may “practice” these skills with a patient, community member, neighbor, friend, colleague, or loved one. (If an older individual is not available, you may choose a younger individual).
2. Complete a physical examination of the client using the “Individual Health History and Examination Assignment” resource. Use the “Functional Health PatternAssessment” resource as a guideline to assist you in completing the template.
3. Document findings of complete physical examination in Situation-Background-Assessment-Recommendation (SBAR) format. Refer to the sample SBAR Template located on the National Nurse Leadership Council website at .
4. as a guide. Document the findings of the physical examination in the assessment worksheet.
5. Using the “Individual Health History and Examination Assignment” resource, provide the physical examination findings summary with planned interventions for the client. Include any community services in the interventions.

APA format is not required, but solid academic writing is expected.

HEALTH ASSESSMENT – WELL OLDER ADULT

DEMOGRAPHICS:

Initials:            DOB:              Marital Status:  Married

Gender:                         Ethnicity/Culture:  Caucasian

CURRENT HEALTH STATUS:

JH considers himself to be in relatively good health, despite his illness and hospitalization two years ago. JH admits to exercising regularly and watching his diet in order to stay healthy. He admits to seeing a doctor on a regular basis and going to cardiac rehab twice a week. JH admits that his health has been excellent over the last year as he recovers from heart disease. He had been hospitalized for two months in early 2012 due to an infection around his heart. The patient admits to smoking in the past but hasn’t smoked in two years. He still has a couple glasses of red wine with dinner every night. Patient takes a prescription blood pressure medication, as well as OTC antacids and allergy medications, but cannot recall the names. Pollen, walnuts, dust, and mold are all allergens for JH. He admits to being UTD on all medications, including those for influenza, shingles, hepatitis B, and pneumococcal disease. Patient always wears his seat belt while in the hospital and has never been in an accident or been involved in one. He denies knowing CPR or first aid.JH considers him self to be a somewhat health person besides his illness and hospitalization 2 years ago.  To stay healthy, JH admits to exercising regularly and being aware of his diet.  He admits to visiting a health care provider regularly and attends cardiac rehab twice per week.  JH admits that his health has been very good over the past year as he continues to recover from his heart disease. In early 2012, he had been hospitalized for two months with an infection around his heart.  Patient admits to smoking in the past but quit two years ago. He continues to drink a couple glasses of red wine at dinner everyday.  Patient takes a prescription medication for his Blood Pressure along with OTC antacids and allergy medications but does not remember the names.  JH is allergic to pollen, walnuts, dust and mold.  He admits to being UTD on all medications including influenza, shingles, hepB and pneumococcal.  Patient wears his seat belt every time he is in the care and has never had any accidents nor been involved in one.  He denies knowing first aid/CPR.

ALSO READ:

FUNCTIONAL HEALTH PATTERNS:

ACTIVITY/EXERCISE:

JH attends cardiac rehab twice a week, exercising on the recumbent bike, hand weights and sometimes the treadmill.  He does not like using the treadmill.  His leisure activates used to include skiing but since his hospitalization he has slowed down on this activity. He now enjoys sailing in the summertime.  JH has a shoulder pad prosthesis since the amputation of his right clavicle/ scapula for osteosarcoma in 1962.  He denies needing a cane, walker or wheelchair.

SLEEP/REST :

JH  admits to sleeping 6.5-7 hours per night and wakes up feeling rested.  He denies napping during the day.  He retires at 9:30pm and awakens at 4:45am.  He denies any problems with sleeplessness and the used of sleep aids.

CARDIOVASCULAR/RESPIRATORY:

BP:120/60                     Radial Pulse:_________       Rhythm: A-fib/flutter

Respirations:  18

JH admits to chest pain and SOB.  He denies cough, distended neck veins, edema, cyanosis and varicosities.

NEUROMUSCULAR/COGNITION:

JH speaks English.  He claims he used to have bad migraines but doesn’t anymore.  He has had 2-3 seizures a couple years ago but has been sense treated.  Patient admits to having balance problems in the past. He wears glasses for reading.  JH denies problems with dizziness, speech impediment, walking and visual problems.  He does not use a hearing aid.  UTA date of last hearing or eye exam.  He denies any problem with memory.

NUTRITIONAL/METABOLIC:

Height: 6’2.5”  Weight 165 lbs

JH eats three full meals a day and denies snacking.  He admits to not drinking enough water.  He does not have dentures but has crowns. His last dental exam was a couple months ago.  He denies weight loss and weight gain.  JH is allergic to walnuts.  He denies GI bleeding, difficulty swallowing, nausea, vomiting, anorexia and bulimia.

SELF-PERCEPTIONS/COPING/

JH’s friends would describe him as friendly, positive and sometimes funny.  His source of strength and hope comes from God and his family and friends.  He attends church at least once a week but often times multiple times per week.

PH admits that his health problems have affected his skiing but he has not stopped completely.  He denies feelings of anger, fear, anxiety and depression but says the biggest negativity in his life is his impatience.  He deals with this but just brushing it off and occasionally swearing.  The only significant loss/change in this life was his hospitalization two years ago.  If he could changes one thing to improve his quality of life it would be to be more generous.

CULTURAL ASSESSMENT

Patient denies his cultural background affecting his health care needs.  He is Caucasian with his cultural background being English and Irish. His family shows they care by giving hugs and kisses.

ILLNESS BELIEFS AND CUSTOMS

JH said that people become ill when they are ill or when there is a lot of tension.  When he is sick, he likes to pray, relax and tries to be patient,  When his loved ones are sick he prays for them, cares for them and is there for them.

INTERPERSONAL RELATIONS

JH defines his family as terrific.  He has four adult kids and a wife of 47 years.  He denies specific duties for men women and children in a family. Growing up both him and his wife disciplined the children but now they live alone and take care of themselves and their families.  JH admits that the most important aspect of life is leading a good life full of gratitude.  There are no topics not discussed in their household.  In his home they only speak English.  JH is a self-employed attorney. He admits to finances influencing his life.  He graduated form law school. His wife and three of his children graduated from college one having his doctorate.

Replies

When considering comparing physical assessments of a child versus an adult, the nurse must recognize that there are key differences between the two examinations. A physical assessment (PA) with an adult starts with assessing vitals, mood, hygiene, demeanor, and level of consciousness. The nurse has an opportunity to observe non-verbal forms of responses to questions to incorporate subjective and objective observations. Assessment of a child, however, relies heavily on objective observation from the patient and the parent’s input. The nurse must remain familiar with stages of development to better identify behavior outside of the norm and to properly educate the parent to know when to seek assistance upon noticing abnormalities. While both children and adults have targeted milestones, milestones among adults may vary depending on societal norms. Reaching milestones for children have a heavy dependence on their environment, family history, and cultural and traditional influences. The text mentions many factors to consider when assessing a child. One of which is nutrition. This aspect is often influenced by culture and family traditions. According to the CDC, more than 12 million children are obese (Falkner, 2018) and are at risk of co-morbidities such as heart disease, malnourishment despite being overweight, and chronic diseases. The nurse has an opportunity to provide patient education to the parent, with the child being a passive listener. In doing so, it is critical that the nurse put aside biases and present options and information as opposed to judgement (Falkner, 2018).

When involving the pediatric patient, therapeutic communication is key. The nurse will observe body language and pick up on ques in instances where the child may begin to withdraw or be uncomfortable. Allowing the child to participate in the assessment process may help them become more comfortable. Perhaps allow child to hold and use stethoscope, therapeutic touch and vivid interaction like asking the patient to say “aaaww”, positive reinforcement such as saying “good job”, and the use of comfort objects to demonstrating what will take place in the PA on a teddy bear are all methods that encourage engagement of a child patient.

Reference

Falkner, A. (2018). Grand Canyon University (E.D). Age-Appropriate Approach to Pediatric Health Care Assessment. Retrieved from .

• MG

Mayreth Gonzalez Pena

replied toLatasha Brooks

Feb 5, 2022, 11:34 AM(edited)

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Replies to Latasha Brooks

Latasha,

Children can have a lot of reservations when it comes to a visit to the health care provider. After all, what isn’t there to be afraid of. Strange new surroundings, noises, people, and of course the dreaded shots. In fact, one in twenty-five parents has canceled doctor’s appointments for their child due to the fear of shots alone (Michigan Medicine – University of Michigan, 2018). Children’s fears and anxiety also interfere with the parent’s ability to ask questions and provide information to the health care staff (Michigan Medicine – University of Michigan, 2018). However, regular checkups and vaccinations are critical during early childhood. The fundamental element with children is building trust. There are three recommendations that I was able to find.

First, get to know the child. This starts with greeting the patient first (the child) then the parent(s). This will show the child that they are the important one and starts the building of trust. Get down to their level, or have a parent hold them when speaking to them. Talk to the child and find out about them and what it is that they like to do (J & D Ultracare, 2019). Secondly, Create a comfortable environment for the child. Make the examination room look less like a medical office. Have an area for them to play with toys, books, and drawing boards. These items can be used as distraction tools to help calm the child during the visit. Even ask them to help get ready for the exam if possible (J & D Ultracare, 2019). And thirdly, just slow down and take your time. Try not to just jump right into the exam. Explain what you are doing and why. Allow them to touch and try things out. If the child’s anxiety is still too great, let them return to playing for a little bit. This will build a sense of trust for them (J & D Ultracare, 2019).

References

J & D Ultracare. (2019, December 17). 3 ways for pediatric nurses to build trust with child patients.

connect2local.com. 

Michigan Medicine – University of Michigan. (2018). Half of parents say their preschooler fears doctor’s visits.

   Science Daily. Retrieved October 15, 2018, from

Describe two external stressors that are unique to adolescents. Discuss what risk-taking behaviors may result from the external stressors and what support or coping mechanism can be introduced.

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Introduction

Bullying is defined as seeking to harm, intimidate, or coerce someone perceived as vulnerable. Bullying within the adolescent community affects about 20-30 % of students who admit being the perpetrator or victim of such harassment (Faulkner, 2018).

Describe two stressors that are unique to adolescents

Bullying and identity confusion are two stressors affecting adolescent population. Bullying in any form can lead to teen depression or suicide (Falkner, 2018). Educating students, parents, professionals and communities on effects of bullying such as teen suicide and depression is imperative to stop the trend. Signs and symptoms of depression are: loss of interest in activities, sadness or hopelessness, irritability, withdrawal from friends and family, changes in eating and sleeping habits, feeling of guilt, lack of motivation/enthusiasm, fatigue and suicidal ideation..

Risk taking behaviors resulting from the external stressors and the coping mechanism

Low socioeconomic status, being pessimistic, cognitive factors, and gender are contributing factors that can lead to higher risk of adolescent depression (Kislitsyna, 2010). Females may be at a greater risk for developing depression because girls are more socially oriented, more dependent on positive social relations and more vulnerable to loss of such relations. Adolescents living with guardians that are depressed may also become depressed. The coping mechanisms are eating healthily, adequate exercising, sleeping adequately and building adequate relaxation time into busy schedules for teenagers. In addition, parents and caregivers should learn to listen carefully to teenager`s problems and support them in sports and other pro-social activities.

Conclusion

People who force and those who are bullied have been found have suicidal ideation, physical injury, somatic problems, anxiety, loe self esteem, depression and school absenteeism than those not involved with bullying (Klein, Myhre, & Ahrendt, 2013).

References

Falkner, A. (2018). Adolescent Assessment. Health Assessment: Foundations for Effective Practice. Retrieved from: https://lc.gcumedia.com/nrs434vn/health-assessment-foundations-for-effective-practice/v1.1/#/chapter/3

Kislitsyna, O. (2010). The social and economic risk factors of mental disorders of adolescents. Russian Education and Society. 52(10). 66-84 DOI:10.2753/RES1060-9393521005

Klein. D.A, Myhre. k.k..& Ahrendt. D.M. (2013). Bullying Among Adolescents: A Challenging in Primary Care. Am Fam Physician. Vol 88(2):87-92.Retrieved from https://www.aafp.org/afp/2013/0715/p87.html

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