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This patient analysis template includes an overview of the interview and the systems that you reviewed for your volunteer patient for Final Project Part I, as well as an interpretation of the findings from the physical health assessment, possible collaborative diagnoses, and health promotion recommendations.

Complete this template by replacing the bracketed text with the relevant information.

1. Patient Identification

a. Initials used for name (make sure there are no other identifiers)

[C.K]

b. Age, sex, race, marital status

[28, Male, African-American, Single

c. Any Information that needs to be known immediately—e.g., deafness, blindness.

[None at this time.]

2. Results and Treatment

a. Provide an overview of the information collected in the patient health history in Module Three. How did this inform the comprehensive health assessment that you conducted?

After interviewing with my client, I was able to collect some vital health information. The client said he rarely exercises and his nature for having no interest in cooking made him opt to eat fried foods from a nearby local restaurant. His blood pressure level was 141/91, which was an improvement from the past recording of 153/99, as stated in his health report. He says he is not having any stressing factor at the moment. Almost all of his body systems were normal, which showed there was no record of palpitation. Though, when his HBP fluctuates, he said he couldn’t tell when at home. His mother had HBP, while his dad died from diabetes. He reports that he attempts to eat well, yet he enjoys consuming food high in cholesterol, loves salmon, and lots of fried food. He stopped the habit of taking caffeinated products and drinks. He does not smoke while he enjoys taking some drinks with his friends.

b. Interpret your findings for each system from the comprehensive, client-centered, head-to-toe health assessment that you conducted. Make sure that you discuss the applicable anatomical, physiological, psychological, nutritional, and cultural factors that contributed to your interpretation.

I conducted an examination of every body system for my volunteer, from the head-to-toe analysis. A nurse using her cultural competence can collect valuable information from this client’s health status. After my examination, I realized he experiences difficulties at home, like exercising regularly and taking a well-balanced diet. His physiological, psychological and cultural factors were all normal because at the moment he has not been diagnosed for any disease.

c. What are the appropriate treatments and follow-up care for your client? Use evidence and research to support your recommendations.

While at home, I recommend my client to continue exercising may be at least 30 minutes per day plus eating balanced healthy diets. I will educate him to do lightweight exercise activities, like jogging, walking and lifting lightweight loads. I will advise him to decrease eating fried foods high in sodium and eat low-fat foods.

d. Explain an appropriate communication plan to inform the client of relevant treatments and follow-up care.

An appropriate communication plan between my client and the medical attendant care is to emphasize on follow up after discharge from the clinic. This follows up must be accompanied by healthy eating and doing regular physical activities. Additionally, my volunteer needs to be couched and handed a question checklist that will enhance his rapport with the clinician. He has an incredibly supportive family, so I would urge him to maintain those relationships.

3. Diagnosis

a. Formulate multiple client-centered, collaborative diagnoses for your practice client. Support your diagnoses with health assessment data and evidence-based research.

The most significant goal I want my volunteer not to lose focus on is to continue maintaining a healthy lifestyle because he is at risk of developing other conditions like diabetes or hypertension. My client-centered approach is to have open communication and advise him on the importance of maintaining a healthy and active lifestyle. He needs to change his diet. Additionally, he needs to understand; despite him having a higher chance of becoming diabetic or developing hypertension, he should know he has the full control of his health.

b. How did you narrow down your multiple collaborative diagnoses to one clear collaborative diagnosis? Support your reasoning with health assessment data and evidence-based research.

Interviewing my volunteer as well as examining the clinical history are the approaches, I used to narrow down to a precise collaborative diagnosis plus also developing a strong foundation relationship with my volunteer. His past care helped me get to identify some issues that I had to build upon during my interview to recommend best patient-centered care and treatment. Throughout the interview session, I asked a question related to every body system.

c. Research and evaluate at least two health promotion tools for their use in preventative health for your client.

The first health promotion tool I will use is health impact assessment (HIA) because I will not only apply it to assess my client’s health implications but also, helping him make health implications visible. I will set achievable goals for him, considering his financial status. The second tool will be Social impact assessment (SIA) because it will help me adopt a more democratic and participatory approach by involving home care nurses and relatives (Nelson & Staggers, 2016). Likewise, I might want to teach him on life expectancy changes that will happen as he ages so he can proceed with a healthy way of life.

d. Recommend health promotion tools that will result in improved patient outcomes or promote health maintenance. Be sure to support your recommendations with evidence-based research. (This will be more fully developed in your Final Project Part 2).

When recommending any health promotion tool, it is advisable to understand the cultural, social and environmental factors surrounding the patient. In this case, my volunteer is a young millennial man who understands how to use technological devices; therefore, I will recommend providing online teaching as an education platform for him. The general rule via this platform is to make sure the client understands what I am saying and shunning jargon clinical words that will cause confusion and miscommunication (Bender, 2016).

References

Bender, M. (2016). Clinical nurse leader integration into practice: developing theory to guide best practice. Journal of Professional Nursing, 32(1), 32-40.

Nelson, R., & Staggers, N. (2016). Health Informatics-E-Book: An Interprofessional Approach. Elsevier Health Sciences.