dr.nickavita

Running head: PHYSICAL ASSESSMENT 1

Health and Physical Assessment

Student Name

Chamberlain College of Nursing

NR 304: Health Assessment II

August 2017

PHYSICAL ASSESSMENT 2

Health and Physical Assessment

Subjective Data

 Demographic Data o H.W. o 95-year-old female o SNF in Atlanta o DNR

 Reason for Care o Fracture of left clavicle o Frequent falls

 History of Present Illness o Patient resided at assisted living prior to admission o Increase in falls over past 6 months o 15% weight loss over past 6 months o Family requested admission to SNF

 Perception of Health o Patient states she is “tired”

 Past Medical History/Family Medical History o Allergies to codeine and penicillin o Malignant neoplasm of breast o Primary HTN o Patient suffered MI in 2000; quit smoking after MI o Unable to provide family history

 Review of Systems o Neurological – use of glasses; decrease auditory acuity o HEENT and Neck – no abnormalities o Cardiology – MI in 2000; no abnormalities o Respiratory – complains of cough x1 week; 2L/min via NC o Gastrointestinal – no abnormalities o Integumentary – complains of excessively dry skin o Musculoskeletal – requires wheelchair for mobility; pain in left shoulder

secondary to fracture (constant, dull pain; worsened by movement, relieved by

rest; does not radiate)

o Peripheral Vascular – no abnormalities

 Developmental Considerations o Integrity vs. despair o Patient has achieved integrity

 Cultural Considerations o N/A

 Psychosocial Considerations o Risk for low self esteem o Risk for social isolation

 Collaborative Resources o Patient has visitors every week

HEALTH AND PHYSICAL ASSESSMENT 3

o Patient usually participates in SNF activities with other residents o Case management involved with patient

Objective Data

Patient alert and oriented x2. Unable to state year and current location. Patient reoriented.

No signs of acute distress noted. Patient is pleasant and cooperative. Patient’s stature is erect.

Patient appears frail and somewhat sick. Kyphosis noted. Patient’s skin is intact, warm, and dry.

Patient’s skin turgor is poor; minimal tenting noted. Patient has a Braden scale of 15. Patient’s

face is symmetrical. Nose and trachea are midline. Patient has full ROM in neck; no pulsations,

masses, or JVD noted. Patient has a persistent dry cough. Respiratory rate is 18 breaths per

minute. Oxygen saturation is 94% on 2L/min via NC. Lung sounds are diminished in lower

lobes, but clear otherwise. S1, S2 noted. Apical heart rate is 61 beats per minute and regular. No

murmurs noted. Blood pressure is 134/69 on the right upper extremity. Capillary refill is <3

seconds in upper and lower extremities. Peripheral pulses are 1+ and equal bilaterally. Abdomen

is flat; no pulsations or masses noted. Bowel sounds hypoactive x4 quadrants. No tenderness

noted in the abdomen. Patient is continent of both bowel and bladder. Last BM was 2 days ago.

Patient has severely limited ROM and is non-weight bearing in left upper extremity due to a

clavicular fracture 6 months ago secondary to a fall at assisted living. Minimally limited ROM in

all other extremities. -----------------------------------------------------------Student Name, SN

Needs Assessment and Education

Maintaining patient safety is the concern of every nurse. Patients that are at high risk to

fall or patients that have a history of falls especially have a need for education regarding factors

that put them at a higher risk and how to maintain their personal safety. H.W. has an increase in

falls, the most recent of which moved her from an assisted living facility to a SNF. In addition to

the transfer to a higher level of care, the patient also suffered a clavicular fracture.

HEALTH AND PHYSICAL ASSESSMENT 4

Patient falls are of such high concern that The Joint Commission has even developed

National Patient Safety Goals related to “reducing the risk of patient harm resulting from falls”

(Madhavanpraphakara, 2012, p. 92). Education related to fall risk would help H.W. to

understand why she is at a high risk to fall and how she can prevent falls in the future.

Due to patient H.W.’s decreased range of motion in all extremities, education should be

provided regarding range of motion exercises and benefits. Even though H.W. uses the

wheelchair for mobility, she is still out of the chair to the bathroom and occasionally for physical

therapy. Maintaining an appropriate level of range of motion will allow her to “improve joint

flexibility and…strengthen the muscles…of the targeted joint” (Schub & Caple, 2016, p. 1). Due

to a clavicular facture on the left side, H.W. may not be able to perform range of motion on the

left arm, but for all other extremities, she would benefit from active or passive range of motion

several times a day. H.W. has a significant history of falls, and strengthening the muscles in her

knees and hips may help to make her steadier or prevent further deterioration.

Reflection

Therapeutic communication plays a large role in completing a proper assessment of a

patient. I have nearly 3 years of experience in the medical field providing direct patient care, and

as result, I’ve grown comfortable speaking to patients. However, having to interact with people

as a nurse is a very different experience. I felt that I needed to convey a larger sense of

responsibility and confidence. Conveying a sense of confidence helps patients to trust and

confide in the nurse.

One of the barriers that I experienced in talking to my patient was her mild confusion.

Occasionally I had to reorient my patient to her situation. This, combined with H.W.’s decreased

auditory acuity, often created difficulties in communicating. As a result, I had to ensure I was

HEALTH AND PHYSICAL ASSESSMENT 5

standing close enough to my patient that she could read my lips and speak loudly enough so that

she could hear me as clearly as possible. While this barrier seems rather common, it can be easy

for information to be misconstrued when one of the communicators has difficulty hearing.

Past medical history and family medical history are important components to a person’s

physical health. In order to better complete this assignment, I would have liked to have had

access to the patient’s medical history. Due to her mental state, H.W. was unable to provide her

personal medical history or her family history. Of course, a plan of care can still be developed

without that information, but at times it can provide insight into the patient’s current health

status.

In the future, something I would like to focus on is changing the positioning of myself

and the patient during the interview. During the interview I conducted, my patient was sitting in

her wheelchair and I was standing in the room. There were no chairs for me to sit in, so I had to

crouch down and bend over to be close to my patient. In the future, better positioning would be

more comfortable for myself and my patient.

HEALTH AND PHYSICAL ASSESSMENT 6

References

Madhavanpraphakara, G. K. (2012). Patient safety and nursing education. International Journal

Of Nursing Education, 4(2), 92-96.

Schub, E., Caple, C. (2016). Range-of-Motion Exercises, Active: Teaching. Nursing Practice &

Skill, 1-8. Retrieved from

http://eds.a.ebscohost.com.proxy.chamberlain.edu:8080/eds/pdfviewer/pdfviewer?sid=b9

4a5144-09b4-4ab9-8c7f-d31af757f527%40sessionmgr4007&vid=2&hid=4113