Nursing Grand Rounds presentation 2

Nursing Grand Rounds Presentation Part 1: Holistic Assessment Form

Part A: Student and Participant Data

1. Student name: Heidi Lugo

2. Participant assessed (initials only): J.D

3. Participant’s age:45

4. Participant's gender (select one): Male

5. Briefly explain how the student knows the participant: I am a registered nurse working on the Medical Surgical unit at HCA Florida Mercy Hospital. I have known J.D. for several years as a colleague and a friend on the same unit. J.D. is a fellow nurse, and we have developed a close professional relationship over time. I am aware of J.D.'s recent diagnosis of diverticulitis, a painful gastrointestinal condition characterized by inflamed pouches in the colon. J.D. approached me for support and advice on managing his condition and its impact on his work and daily life. I have offered her assistance and guidance in managing diverticulitis while respecting his privacy and consent.

Part B: Evaluating Medical History

6. Drug/medication allergy: Yes No If yes, please specify: NO

7. Food/material/environmental allergy: Yes No If yes, please specify: NO

8. Please complete the participant and family health history table below.

Participant and Family Health History
		Specify alterations/abnormal findings
Category	Alterations (Yes/No)	Participant	Family members
Cardiovascular disorders	No
Respiratory disorders	No
Neurological disorders	No
Musculoskeletal disorders	No
Kidney disorders	No
Liver disorders	No
Gastrointestinal disorders	Yes	Diverticulitis	Father (Gastritis)
Metabolic and endocrine disorders	No
Genitourinary disorders	No
Lymphatic/immune system disorders	No
Infections/infectious disease	No
Blood disorders	No
Skin, hair, and nail disorders	No
Sleep disorders	No
Mental or behavioral health disorders	No
Other significant health alterations	No

9. Are vaccinations up to date? Yes

10. Does the participant participate in any complementary or alternative therapies, such as acupuncture, aromatherapy, hydrotherapy, etc.? No

Part C: Medication and Other History

1. Please list all current medications and supplements the participant is taking, including the dose and frequency.

Medication 1: Metronidazole (Flagyl)

Dose: 500mg

Frequency: Twice daily

Medication 2: Probiotic supplement

Dose: 1 capsule

Frequency: Once daily

2. Past surgeries? (Please specify and include year)

Appendectomy in 2005

3. Date of last dental exam?

June 15, 2023

4. Date of last eye exam? November 10, 2022

a. Does the participant wear glasses or contacts? Yes

b. Does the participant report other visual concerns? No

5. Has the participant recently experienced unplanned weight loss or gain? NO

6. Additional screenings completed in the last two years:

a. Mammogram Yes No Date: Date: January 20, 2023

b. PSA Yes No Date: NO

c. Colonoscopy Yes No Date: August 5, 2022

d. Other (please specify)

e. N/A

Part D: Physical Assessment Findings

7. Initial vital signs:

a. Pulse: 76 beats per minute

b. Blood pressure: 128/78 mm Hg (reported by the participant from last check)

c. Respiratory rate: 18 breaths per minute

d. Temperature: 98.6°F (37°C)

e. Pulse oximetry: 97% (reported by the participant from last check)

8. Orientation: Alert and oriented to person, place, time, and situation (oriented x4).

9. Pupils: Pupils equal, round, and reactive to light (PERRLA).

10. Head, ears, eyes, nose, and throat: Normocephalic, atraumatic. Ears, eyes, nose, and throat appear normal.

11. Pulses: Radial and pedal pulses are strong and equal bilaterally.

12. Heart rate and rhythm: Heart rate is regular at 76 beats per minute.

13. Pulse strength: Pulse strength is strong and equal bilaterally.

14. Capillary refill: Capillary refill is less than 2 seconds.

15. Respiratory rate and effort: Respiratory rate is within normal limits, and breathing effort is regular and unlabored.

16. Lung sounds: Lung sounds are clear to auscultation bilaterally.

17. Abdominal assessment: Abdomen is soft and non-tender on palpation.

18. Bowel sounds: Bowel sounds are present in all quadrants.

19. Date of last bowel movement: Last bowel movement was yesterday.

20. Urinary status: Participant reports normal urinary frequency and no issues.

21. Skin color and temperature: Skin color is normal and warm to touch.

22. Wounds or bruises? No wounds or bruises noted.

23. Assessment of mucous membranes: Mucous membranes are pink and moist.

24. Extremity strength and ROM: Full strength and ROM in all extremities.

25. Gait: Participant's gait is steady and coordinated.

26. Presence of tubes or drains: No tubes or drains present.

27. Pain assessment: Participant reports no pain or discomfort at this time.

Part D: Cultural and Spiritual Assessment

28. What culture does the participant identify with? The participant identifies with African American culture.

29. Sexual orientation of the participant? Heterosexual

30. How does the participant describe their faith or belief system? The participant describes their faith as Christian and holds strong Christian beliefs.

31. Is the participant part of a religious community? Yes

a. If so, which one? The participant is a member of St. John's Baptist Church.

b. Does the participant have personal spiritual beliefs that are independent of organized religion? Yes, the participant also has personal spiritual beliefs that go beyond organized religion.

32. What aspects of spiritual care are important to the participant? The participant values prayer, seeking solace in their faith during times of difficulty, and maintaining a connection to their church community.

33. Has the participant ever experienced bias or exclusion based on race, faith, culture, or sexuality? The participant has experienced some instances of bias and exclusion based on their race, primarily in the form of microaggressions.

a. Describe how the participant handled these bias’s or exclusions and how it impacted their health.

The participant handled these situations by addressing them assertively and seeking support from friends and their church community. While these experiences have been challenging, the participant's faith and social support have helped him cope and maintain his mental and emotional well-being. There has been no significant impact on his physical health.

Part E: Social History

34. Occupation: The participant is employed as a Registered Nurse in the Medical Surgical unit.

35. What is the highest level of education completed by the participant? Bachelor of Science in Nursing (BSN).

36. Tobacco use (type and frequency): The participant does not use tobacco.

37. Alcohol use (average number of drinks per week): The participant consumes an average of 1-2 alcoholic drinks per week.

38. Recreational drug use (type): The participant does not use recreational drugs.

39. Is the participant sexually active? Yes

a. Birth control method: The participant uses oral contraceptives.

b. History of sexually transmitted infections: No known history of sexually transmitted infections.

40. How often does the participant exercise? What type? The participant exercises 3-4 times a week, primarily engaging in aerobic activities like jogging and cycling.

41. Does the participant feel supported or have family/friends they can turn to? Yes

a. If no, describe how the participant responds to and copes with stressful events? N/A

b. What resources does the participant utilize for support? The participant relies on their close-knit family and church community for emotional support during stressful events.

Part F: Additional Health Considerations

42. How would you rate your current health? Good

43. What factors contributed to your personal health rating? The participant rates their health as "Good" due to regular exercise, a balanced diet, and adherence to medical advice for managing their diverticulitis. They also credit their faith and social support system for contributing to their overall well-being.

44. What (if any) are your health goals? The participant's health goals include maintaining a healthy lifestyle, managing their diverticulitis effectively, and continuing their regular exercise routine. They also aim to deepen their spiritual practices and involvement in their church community.

45. What health care topic(s) do you want to learn more about? The participant expresses an interest in learning more about dietary and lifestyle strategies for managing gastrointestinal conditions like diverticulitis. They are also interested in exploring holistic approaches to health and wellness that align with their faith and spirituality.

Part G: Selected Health Alteration

Please state the participant’s selected health alteration that will be the primary focus of the Week 5 Nursing Grand Rounds Presentation:

The participant's selected health alteration that will be the primary focus of the Week 5 Nursing Grand Rounds Presentation is "Diverticulitis."