NSN701 Advanced Health Assessment
Question:
Part 1
Choose an assessment tool or framework that suits the needs of your patient and/or speciality area of clinical practice (see ‘some points to consider’ for framework examples).
Provide a justification for your choice of health assessment framework. This justification needs to be supported by literature.
Select a patient (either upon admission or an in-patient for whom you care over a single shift). Identify at what stage of the patient’s admission your health assessment was undertaken in the introduction of your assessment item.
gain consent and then perform a thorough health assessment.
Present the patient’s assessment data, include all findings, subjective and objective data logically and clearly. You may present this section under key areas/headings of your framework and then in bullet point form.
Your assessment data should identify normal ranges for this health area and highlight pertinent findings/observations (use italics to highlight).
It is expected that you use appropriate literature to support your claims.
Part 2
Identify all the patient’s actual and potential problems, within reason.
Select the most important four problems based on the assessment data gathered in Part 1.
Justify and explain why these are priorities for the patient, using the data you have collected and evidence-based literature.
Include a copy of the health assessment framework in your submission (this will not be included in your word count).
Answer:
Introduction:
Head to toe/body systems assessment could be used as an assessment tool that suits the needs of a patient. Health assessment framework enable healthcare professionals to apply their knowledge from diverse resources into particular clinical situations (Harris-Roxas, & Harris, 2013). A comprehensive assessment is performed upon admission of a patient, at the commencement of individual shift and while it is thought to be necessary by the patient’s situation and the hemodynamic status (Kress, Su, & Wang, 2016). The reason behind selecting this health assessment is that it comprises all the associated body systems and findings inform the care professionals regarding patient’s overall condition. Any sort of abnormal findings need to be followed-up by providing specific focus on the affected system of a patient. Physical assessments includes gathering objective data by using various techniques like palpation, inspection, auscultation, percussion and so on, as appropriate (McCarthy, 2014).
Smith is a 40 years old man, who is being admitted to the ward from operating ward after a Transurethral Resection of the Prostate (TURP). Smith is presently under an Urologist’s care, who is having a history of nocturia and urinary retention because of benign prostatic hyperplasia. Prior admission, Smith was in good health, married to his long-term girlfriend. Smith lives in an apartment with his wife, and both are working as computer programmer. Smith has a medical history of anxiety and depression that is presently under control with regular medication. He also visits community health team along with his wife, once in a week. Before his transfer, observations have been documented and have remained stable during recovery:
Vital signs: Glasgow Coma Scale: GCS 14 (E=5, V=4, M=5)
Blood Pressure: 135/85 mmHg
Heart Rate: 82 bpm regular
Respiratory Rate: 15 bpm
Oxygen Saturation: 99% on nasal [email protected]
Temperature: 37?c
Pain Score: 4/10 discomfort
Output 35mls per hr
Catheter Check:
Connection points-intact and closed
Balloon- inflated with 10mls
Bag placement- below bladder
Urine- reddish pink colour with small clots
Drainage- free flowing
Drainage tubing- no leaks
Medical Orders
Regular postoperative observations and assessment
Monitoring of strict fluid
Continuous bladder irrigation
Clear fluid administration (tolerated)
Management of pain
Prescribed Medication
Sodium chloride: 1000mls over 8 hours
Oral Paracetamol: 1g with 4 hrs interval, Morphine 5mg prn, Oxycodone 5-10 mg with 4 hrs interval
Enoxaparin 20mg S/C daily
Senna daily with Coloxyl
Intramuscular Ondansetron: 4mg prn 12 hourly
After the lunch break, it is checked that Smith is feeling restless, groaning, looks pale, eyes are clenched closed and having tachypnoea.
Vital Signs: Glasgow Coma Scale: GCS 15 (E=5, V=4, M=6)
Blood Pressure: 96/60 mmHg
Heart Rate: 140 bpm regular
Respiratory Rate: 25bpm
Oxygen Saturation: 95% on room air
Temperature: 37?c
Pain Score: 8/10
Other: little blood clots in tubing
Bladder irrigation fluid balance:
- Total fluid administration for irrigation = 2800 mls normal saline
- Total output in catheter bag = 1200 mls
- Fluid balance= 1600 ml deficit thus a positive balance [A-B=C, determines fluid deficit or excess]
Patient consent is of utmost important prior performing a health assessment. This ensures patient’s involvement in health care related decision making. Morgenstern, (2010) stated that informed consent should be obtained prior conducting any healthcare intervention of an individual. For Smith’s case it is important because his medical intervention necessitates the use of catheter.
Head to toe/body systems Assessment
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General appearance- anxiety, hygiene level, body position, mobility, speech pattern |
Alteration may demonstrate neuronal impairment |
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Skin, nail, hair Assess rashes, lesions Palpate skin for temperature Check pressure areas Inspect hair, scalp |
Redness of skin necessitates patient repositioning Bilateral oedema may indicate kidney failure |
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Head, neck Inspect eye drainage, pupillary reaction to light, inspect mouth, denture, facial symmetry |
Dry mucous membrane shows decreased hydration Facial asymmetry shows neurological issues |
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Chest Inspect retraction/expansion, work of breathing, jugular distension Palpate lung expansion |
Informs about working ability of the accessory muscle. Use of accessory muscle indicates airway obstruction |
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Abdomen- Inspect abdomen for asymmetry, distension Auscultate bowel sound Palpate four quadrants for bladder distention and pain Check urine output Determine bowel movement and frequency |
Peristalsis with abdominal distension indicates intestinal obstruction Absence of bowel sound may be present after surgery Abnormal findings with bowel may demonstrate urinary function, also necessitates genitourinary assessment |
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Extremities- inspect pressure areas, legs, arms for pain, compare bilaterally Palpate pedal, radial pulse, capillary refill in hands and feet Assess strength of handgrip Assess plantarflex, dorsiflex against resistance Pressure areas and skin integrity |
Asymmetry after palpating pulses, unequal handgrip may demonstrate post-surgical complications |
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Back area- inspect coccyx, spine and back |
Check for abnormalities in spine, skin integrity, pressure area, need regular changes in patient’s position |
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Tubes, drainage- inspect drainage, function and position |
Colour, amount, consistency of drainage is noted as catheter is in use |
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Mobility- determine gait, need for assistive service |
Position patient prior standing, assess risk of falls, if required use mobility aids |
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Document and report assessment findings as per workplace policy |
Timely documentation promote patient safety |
The most important four problems based on the assessment data gathered for Smith could be: risk of impaired urinary elimination, poor renal tissue perfusion, possibility of dysuria and anxiety.
Impaired urinary elimination: microorganisms’ entry inside the urinary tract affects the defence mechanism. Urine washes away the harmful microorganisms present within the urinary tract. Irritation of bladder wall also occurs with the presence of microorganisms and bladder contracts the smooth muscles to eliminate the pathogens with urine (Miranda, Lourenço Junior, Miotto Junior, & Napoleão, 2013). Reducing the risk of impaired urinary elimination would help to evaluate causative factors, evaluate retention, and understand Smith’s extent of interference and hydration level.
It is important to consider in Smith’s care plan as difficulty in urinary elimination may also indicate failure of glomerular filtration as evidenced by decreased excretion of nitrogenous products that are secondary to renal failure.
Renal tissue perfusion: Smith’s proteinuria, hematuria should be noted. This may also include checking increased level of creatinine. Blood Urea Nitrogen alter mentation, which otherwise could affect his psychological health status. Glomerular Filtration Rate may increase blood pressure and rennin. Care providers should check degree of impaired renal function to evaluate renal function and perfusion (Rosenbaum et al., 2013). Sigmund et al., (2012) stated that calories meet the system’s needs, whereas, reducing protein consumption would help in limiting blood urea nitrogen. Stress could increase the effect of illness or force him into inactivity. Poor renal tissue perfusion might increase commitments to promote optical consequences. Proper nursing management may include encouraging patient, establish personal goals, increase patient well-being and enhance recovery.
Capillaries are the integral part of nephrons that carry out oxygenation. While nephrons are impaired due to any kind of renal disease like Pyelonephritis, a progressive decline is evident in terms of kidney perfusion (Kanno, Matsuda, Sakamoto, Higashi, & Yamada, 2013). This type of impaired perfusion affects erythropoietin production by the kidneys. A reduction in the amount of red blood cells will further diminish the supply of oxygen to the kidneys (Lee, Lee, & Cho, 2012). Smith would demonstrate lifestyle change in order to prevent further complications.
Dysuria: Sudden reduction of urinary flow may demonstrate the sign of renal dysfunction. Proper nursing management would enable to maintain good flow of urine and hydration. Also, tachycardia and orthostatic hypotension indicate hypovolemia. Wilbanks, Galbraith, & Geisler, (2014) in this regard have mentioned that reduced urine flow indicates urinary retention and augments pressure on the upper urinary tract. Proper care would help in controlling pain, hence, rest time should be increased, which further ensures comfort and sleep.
Stabilizing dysuria is one of the major care plan for the patient as his pain was not responding to regular paracetamol and it is known from his past medical history that he is allergic to penicillin. So, it is a challenge for the professionals to suitably evaluate whether his present medications are working well to control his painful urination and whether any allergic response is detected after the administration of present medications after the admission to the ward.
Anxiety: Transparent communication ensures patients about their health status and thereby reduces health related anxiety. Involving Smith in his own care would empower him. This further promotes faster recovery.
While transferring Smith from the emergency department, he was oriented and alert, where his Glasgow Coma Scale was 15. His blood pressure was almost normal but with elevated heart rate. Smith required no additional oxygen as his oxygen saturation level was 99%. He was breathing normally and scored 4 out of 10, while accessing pain sensation. This indicates Smith’s suffering from moderate pain. His urine was cloudy and dark with 35mL/hr. output, which is lower than normal (approximately 33.3 – 83.3 mL/hr.), which further demonstrates abnormality in the excretion. Presence of leukocytes shows infection inside the system, as the colorless cells (leukocytes) are involved in fighting with foreign particles (Smith et al., 2015). This indications are necessary for his diagnosis. As nursing care is based on these primary assessment, the care professionals should develop a holistic care plan for Smith.
Smith’s nursing chart should contain 3 major areas, which are pain assessment, catheter check and recording of intake and output of fluids. Nurses needs to commence to provide nursing care upon Smith’s admission to the ward. Pain assessment would enable him to feel comfortable and medication would be administered prn (Kress, Su, & Wang, 2016). This would further help him to avoid episodes of bladder spasms. Smith may feel constricted because of the attached catheter, which is tapped tightly to the leg to control bleeding. The catheter release depends upon the color change (clear/pink/red) in urine. Catheter is generally released if the urine is clear. Keeping a record of fluid intake and output is also important. Bladder irrigation is significant as it helps to keep the urine clear, remove clots from bladder (Onishi, Sasaki, & Hoshina, 2011). This prevents any obstruction within the catheter by any sort of clots formation. Bladder irrigation does not maintain urine production, nor it decreases bleeding, but, once urine is clear, the process is stopped. If documentation of all these clinical procedures are not completed perfectly, the major situation could be Smith’s severe injury. Incorrect information dissemination may also take place within the respective care team.
Smith has been has been prescribed with Enoxaparin 20mg S/C daily, which reduces blood clotting capacity and thus reduces formation of blood clots within the vessels. Enoxaparin binds with an antithrombin to synthesize a complex, which activates clotting factor: Xa, irreversibly. It works less efficiently against thrombin because of its low molecular weight. Escitalopram Oxalate 20mg daily would help to control his anxiety. It belongs to selective serotonin-reuptake inhibitors and has no effect on the dopamine or norepinephrine reuptake. This compound does not antagonize histamine H1 receptors or alpha or beta adrenergic receptors.
Medication order with Intramuscular Ondansetron 4mg prn is also significant as it prevents post-operative vomiting and nausea. In Smith’s condition, he has undergone a transurethral resection of the prostate (Rosenbaum et al., 2013). Though Ondansetron is a well-tolerated medicine, but headache, dizziness, and diarrhoea are majorly reported side effects. Thus nurses should strictly monitor all the dosages and should immediately report to doctor if any adverse sign is identified.
From the above discussion, it could be stated that nursing knowledge involves four major nursing concepts, which are health, client, nursing and environment. Systematic health assessment could be said as a prominent focus of major nursing education. This aspect has attracted the dominance of nursing theories. Nevertheless, irrespective of the practice context, nursing brings into play the systematic evaluation with regard to community or family as client. General idea about human needs offers a crucial theoretical background in order to understand individuals. Using subjective and objective data, the nurses can draw over-all conclusion regarding core human needs. Nevertheless, individualized nursing care integrally necessitates an understanding of typical demand-related goals, which individuals hold to determine if needs are being completely met and assess the status of the individuals in regard to what comprises standard health for a person.
Reference list
Harris-Roxas, B., & Harris, E. (2013). The impact and effectiveness of health impact assessment: A conceptual framework. Environmental Impact Assessment Review, 42, 51-59. https://dx.doi.org/10.1016/j.eiar.2012.09.003
Kanno, T., Matsuda, A., Sakamoto, H., Higashi, Y., & Yamada, H. (2013). Safety and efficacy of ureteroscopy after obstructive pyelonephritis treatment. International Journal Of Urology, 20(9), 917-922. https://dx.doi.org/10.1111/iju.12060
Kress, D., Su, Y., & Wang, H. (2016). Assessment of Primary Health Care System Performance in Nigeria: Using the Primary Health Care Performance Indicator Conceptual Framework. Health Systems & Reform, 2(4), 302-318. https://dx.doi.org/10.1080/23288604.2016.1234861
Lee, J., Lee, Y., & Cho, J. (2012). Risk factors of septic shock in bacteremic acute pyelonephritis patients admitted to an ER. Journal Of Infection And Chemotherapy, 18(1), 130-133. https://dx.doi.org/10.1007/s10156-011-0289-z
McCarthy, I. (2014). Putting the Patient in Patient Reported Outcomes: A Robust Methodology for Health Outcomes Assessment. Health Economics, 24(12), 1588-1603. https://dx.doi.org/10.1002/hec.3113
Miranda, F., Lourenço Junior, L., Miotto Junior, A., & Napoleão, A. (2013). Defining characteristics of the nursing diagnosis impaired urinary elimination in infants: integrative review. Reme: Revista Mineira De Enfermagem, 17(3). https://dx.doi.org/10.5935/1415-2762.20130053
Morgenstern, L. (2010). Patient-Centered Care and Informed Consent. JAMA, 304(4), 409. https://dx.doi.org/10.1001/jama.2010.1029
Onishi, T., Sasaki, T., & Hoshina, A. (2011). 1649The Benefit Of Continuous Saline Bladder Irrigation After Transurethral Resection In Non-Muscular Invasive Bladder Cancer. The Journal Of Urology, 185(4), e662. https://dx.doi.org/10.1016/j.juro.2011.02.1759
Rosenbaum, C., Wach, S., Kunath, F., Wullich, B., Scholbach, T., & Engehausen, D. (2013). Dynamic Tissue Perfusion Measurement: A New Tool for Characterizing Renal Perfusion in Renal Cell Carcinoma Patients. Urologia Internationalis, 90(1), 87-94. https://dx.doi.org/10.1159/000341262
Sigmund, E., Vivier, P., Sui, D., Lamparello, N., Tantillo, K., & Mikheev, A. et al. (2012). Intravoxel Incoherent Motion and Diffusion-Tensor Imaging in Renal Tissue under Hydration and Furosemide Flow Challenges. Radiology, 263(3), 758-769. https://dx.doi.org/10.1148/radiol.12111327
Smith, T., Bohlke, K., Lyman, G., Carson, K., Crawford, J., & Cross, S. et al. (2015). Recommendations for the Use of WBC Growth Factors: American Society of Clinical Oncology Clinical Practice Guideline Update. Journal Of Clinical Oncology, 33(28), 3199-3212. https://dx.doi.org/10.1200/jco.2015.62.3488
Wilbanks, M., Galbraith, J., & Geisler, W. (2014). Dysuria in the Emergency Department: Missed Diagnosis of Chlamydia trachomatis. Western Journal Of Emergency Medicine, 15(2), 227-230. https://dx.doi.org/10.5811/westjem.2013.12.18989.
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