NUR 325 Final Project
To begin a comprehensive assessment, one needs to develop a connection with the patient and this way the patient feels respected and valued. All nursing practice revolves around the nurse-patient relationship which is built on verbal and non-verbal communication (Jensen 2015). Communication is the one of the foundational components of the nurse-patient relationship. Building a good rapport sets the tone for the interview and allows the patient to feel more comfortable with the nurse which then allows the patient to feel more comfortable and honest (Jensen 2015). Within the nurse -patient, the nurse learns certain things about the patient. Such as the patient’s spirituality, psychosocial and culture concerns.
Nurses will use these unique techniques and communication skills to collect complete and accurate data about the health state of patient. Nurses’ will develop the techniques of active listening, confirmation of reflection, explanation, reserve, focusing, clarification and summarizing (Jensen 2015). When assessing Tina, she is quiet in the beginning of our conversation but eventually opens up once empathy and trust is shown to Tina. I started out introducing myself and asked Tina open-ended questions to get the most out of my interview with her. When assessing a patient, a nurse will use three methods; observing, interviewing and examining.
The first assessment technique that was used to assess Tina with each body system was inspection. This technique is an overall general survey and for each body part. This is the one technique that is used for everybody part/system (Jensen 2015). How this is performed is by observing the patient for behaviors and physical characteristics. During inspection, adequate exposure of each body part is necessary (Jensen 2015). The nurse looks for redness, appropriate size, inflammation, color, texture, infected areas, bruising, distention, edema, discharge and lagged movements. A common technique is to note size then symmetry (Jensen 2015).
Palpation is the next technique which is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain and edema. Always inform the patient what body part you are going to touch prior to touching, explain the rational and then ask permission (Jensen 2015). The nurse uses different parts of the hand like the palm or the fingers depending on what you are palpating. The nurse always should avoid causing discomfort or pain while performing this technique.
Palpation which is done for texture, temperature, moisture, to check for appropriate organ size along with the location, tenderness, pain, presence of lumps and for rigidity (Jensen 2015). This is done with light and deep palpation. palpate the skin for moisture, temperature, texture, turgor, and edema. Palpate cranium, temporal artery and temporomandibular Joint.
Palpate frontal and maxillary sinuses. palpate auricle, lobe, and tragus, canal and tympanic membrane Palpate tracheal position midline, palpate carotid pulse, palpate preauricular, postauricular, occipital, and posterior cervical chains (Jensen 2015). Palpate tonsillar, submandibular, submental, and anterior cervical chains. Palpate supraclavicular nodes. Palpate chest for fremitus, thrill, heaves, and PMI (Jensen 2015).
Palpate for abdominal tenderness, distention in all quadrants, liver, spleen, kidneys, aorta, femoral pulses, and inguinal lymph nodes or hernias (Jensen 2015). Palpate dorsalis pedis pulses bilaterally, popliteal pulse and posterior tibial pulse. Assess capillary refill on both feet, then palpate edema on ankle and shin (Jensen 2015). Palpate for tenderness, temperature, lower extremities and joints from hips to toes. Palpate thyroid, spine and scapulae. Test flank tenderness Evaluate circulation, movement, and sensation.
Percussion is the third technique for the physical assessment and this is to produce sound or elicit tenderness. The nurse taps her fingers on the patient which would be similar to tapping drumsticks on a drum (Jensen 2015). If the vibrations travel through dense tissue the percussion sounds are quiet which is normally over bones and if they travel through air or fluid the sounds are louder which would be over lungs and abdomen (Jensen 2015). Percussion is another technique that was used to assess underlying structures of location, size and location.
Percussion sounds are the following: resonance, hyper resonance, tympany, dullness, flatness. Percuss anterior chest from apex to base and sides. Percuss abdomen in all quadrants and for gastric bubble, liver margin at right MCL, and spleen (Jensen 2015). Percuss posterior chest from apex to base to sides.
Auscultation is when you listen for sounds produced by the body which is from movement of organs and tissue and blood vessels (Jensen 2015). This is used with a stethoscope. The most common assessments that auscultation can be heard involves blood pressure, lungs, heart and abdomen (Jensen 2015). The nurse will need a quiet room when performing this technique. Auscultation technique is for listening to sounds produced by the body (Jensen 2015). This is done with a stethoscope. The diaphragm is the flat end of the stethoscope and this is for listening for high pitched sounds which would be for heart, lungs and abdomen (Jensen 2015). The other side is the “bell” which is for low pitched sounds and this would be for blood vessels like the arteries. Auscultate breath sounds (Jensen 2015). Auscultate heart with bell at apex and left sternal border with patient lying down, then auscultate heart with diaphragm in aortic, pulmonic, left sternal border, tricuspid, mitral with patient laying on left side. Auscultate carotid artery. Then auscultate bowel sounds, aorta, renal, and femoral arteries with bell of stethoscope (Jensen 2015).
Inspect overall skin color, no abnormal findings found. Skin does not appear jaundice, pallor, flushing, cyanosis, erythema, ruddy or mottled. Then the breathing effort is evaluated to see if the patient is showing abnormal signs that are dyspnea, head of bed positioned upward to help with breathing or is in tripod position to aid with breathing. Tina’s breathing is not labored a she is not using abdominal muscles to breathe. Observe how patient’s overall appearance presents, what you don’t want to find is that the patient appears older than the actual age or appears ill and if she seems malnourished or overweight. Assess mood to see if patient is calm, pleasant, and cooperative or does the patient have a flat or inappropriate affect, display depression, elation, euphoria, anxiety or irritable. Tina is calm and pleasant. Evaluation of personal hygiene is done to ensure that there is no poor personal hygiene. Inspect patient for poor posture or observe for physical deformities.
Skin, Hair and Nails
Inspection that was done is a close and careful visualization of Tina as a whole then with each body system. Inspection of Tina’s skin which entails the color of skin, is visually done to make sure that the skin is the appropriate color for ethnicity of the patient and to check for any skin infections or lesions. Skin is normally smooth, appropriate color and clear with no acne. Tina’s skin has scattered pustules. Palpation of Tina’s skin resulted in warm, slight dry, intact and good turgor. Tina’s hair has normal distribution and is supple and her scalp is pink, smooth, no flakes, pests which is normal. She does display facial hair on upper lip which is not common with women.
Then the inspection of Tina’s head was done to look for symmetrical structures such as facial structures being symmetric with no edema or deformities. Tina’s head is normocephalic and atraumatic. The skull was inspected to ensure proper shape, size and contour for gender and age. Assessed trigeminal nerve, monitor strength and light touch, three facial branches which is needed to ensure that no facial numbness or facial pain has occurred. Next is to inspect eyelids for swelling or ptosis, eyelashes and eyebrows for equal hair distribution. Palpation of sinuses showed no frontal or maxillary sinus tenderness. Tina’s scalp was palpated which resulted in no masses.
Mouth and Throat
Inspection of the mouth was done with light and tongue blade which is done to rule out any redness or spots. I then inspected inside of Tina’s lips, buccal mucosa, gums, teeth, hard/soft palates, uvula, tonsils, pharynx, tongue, and floor of mouth was done to ensure that there were no lesions, ulcers, inflammation, broken teeth, excessive secretions or dry due to dehydration. Assess tonsils, note mobility of uvula when patient says “ahh”, this is to check that uvula rises which is the cranial nerve X- valgus also the hypoglossal nerve and look for symmetry of tongue when extended which was properly aligned for Tina. Tina’s jaw was palpated and resulted with no clicks and had full range of motion. Palpation of the lymph nodes resulted with no axillary or supraclavicular lymphadenopathy. When Tina’s thyroid was palpated the results were that it was smooth without nodules and no goiter present.
Inspection of Tina’s vision near and distant which the normal is 20/20 vision and Tina was only able to have this with corrective lenses. Inspection of conjunctiva and sclera was completed to make sure that the conjunctiva is moist and that the sclera is white and not discolored. Assess extraocular movements are intact. PERRL was assessed with using a penlight, both pupils are equal, round and reactive to light. Inspection of Tina’s interior eyes with ophthalmoscope which should show red reflex symmetrical, discs cream-colored with sharp margins. Retina is pink, no hemorrhages or exudates and no arteriolar narrowing with macula yellow. Tina’s findings were mild retinopathic changes on right eye and left fundus with sharp disc margins with no hemorrhages.
Tina’s ear alignment was inspected to make sure there were no deformities and tympanic membrane was inspected with the otoscope that should show no discoloration or inflammation. Tina’s nostrils were inspected used by otoscope to make sure that there was no swelling, discharge and bleeding and examined mucosa, turbinates for polyps or swelling which was not seen and septum for any holes or deviation which there was none. Palpation was done on auricle, lobe, tragus and canal. Tina’s ears were without lesions, crusting, masses or tenderness which is expected. Whisper test performed and heard on both ears.
Inspection of Tina’s symmetry of her neck for proper alignment and tested flexion, extension, lateral bending, rotation, range of motion and strength and had no limitations with these movements. Tina’s jugular veins were inspected for any distention which there was none.
Inspected chest wall to see if it was symmetric which it was for Tina, and no deformity or lesions noted. Evaluation of Tina’s nails displayed no clubbing noted. Tina’s breathing effort was observed to make sure it was not labored or have shortness of breath, Tina’s rate rhythm was between 12-20, and position is upright in order to breathe. Tina was assessed for cough and inspect that her sputum was clear. Tina’s precordium was inspected for appropriate size and shape. Palpation of thoracic expansion was symmetric. Tina’s tactile fremitus was palpated which resulted that the anterior and posterior chest walls were found with normal fremitus. Percussions were started with the anterior and posterior chest walls were all found resonant. Breath sounds were auscultated from anterior and posterior were found to have no adventitious sounds throughout. Auscultated anterior and posterior lungs for bronchophony had muffled sounds.
Tina’s bilaterally lower extremities were inspected for edema and none was present. Palpation of Tina’s left, and right carotid artery pulses were found normal which is 2+, no thrill. PMI was palpated at the midclavicular line, 5th intercostal space and no heaves or lifts noted. Pulses of the upper and lower extremities which was the radial and brachial were palpated and found normal at 2+. Auscultation of arteries in the head and neck were found to have no bruit which is normal. Tina’s heart sounds were auscultated: aortic area, pulmonic, tricuspid, mitral, and Erb’s point with the bell showed no S3, S4 which is normal and the auscultated with the diaphragm of the aortic area, pulmonic, tricuspid, mitral, and Erb’s point resulted as normal with RRR, S1, S2, and no murmur. Tina’s bilateral renal, iliac and femoral arteries were auscultated and was found to be normal with no bruit.
Tina’s abdomen was inspected for symmetry, rounded or flat, or visible masses which resulted normal. Inspected stool for color and texture and urine to ensure color is clear and light yellow. Tina reported no nausea, diarrhea or constipation. Evaluate swallowing, chewing, aspiration risk, and special diet. Tina has changed her diet completely to help her control her diabetes. Light palpation of abdomen founded soft, no tenderness or masses. Deep palpation of abdomen resulted with no masses, guarding or rebound. The liver, spleen and kidneys were palpated which resulted normal as in both kidneys and spleen not palpable and no masses and the liver palpated 1cm below right costal margin. Percussed Tina’s spleen which resulted with no dullness and liver span was percussed 7cm MCL on percussion. Abdomen percussed all quadrant which resulted normal with tympanic sounds. Auscultated Tina’s bowel sounds, and all quadrants found normoactive. Auscultated aortic artery which resulted normal since it had no bruit.
Observe range of motion of joints and found without limitations. Inspect skin, symmetry, configuration, and observe respirations and inspect lower back and buttocks then inspect spine. Tina’s hands and bilateral shoulder, elbow, wrist, hip, knee and ankle joints were assessed for swelling or inflammation and were found to have none. No edema, masses or deformity noted with upper and lower bilateral extremities. Strength of bilateral upper extremities and lower extremities all resulted normal strength of 5/5. Tina’s neck was also tested for strength and resulted in the normal range 5/5. Inspection of Tina’s toenails resulted normal without ridges or abnormalities. No edema to ankles or shins, extension of veins and any lesions.
Assess mental status, level of consciousness and orientation. Assess ability to follow commands. Evaluate short and long-term memory by asking questions and this way you can also assess for clear speech and hearing. Performance of finger-to-nose test was completed without difficulty. Palpate dorsalis pedis pulses were positive bilaterally. Performed hand grasp for range of motion and muscle strength. Test muscle strength in hips, knees, and ankles. Test sensation and obtain reflex hammer. Test deep tendon reflexes (DTRs)- patellar, Achilles, and Babinski reflex all resulted with 2+ which is normal. Sensations to bilateral upper extremities and bilateral lower extremities with light touch, dull pain and sharp pain were all found intact. Tina’s position sense was found intact in toes and fingers. Tina correctly identified a coin, paperclip and key with both hands with the stereognosis test. She also tested correctly with the grathesia for one hand identifying the “8” on one palm and the letter “A” in the other palm. Tested sensation with monofilament and Tina was found to have decreased sensation to bilateral forefoot but does have sensation to bilateral heels.
Obtain temperature, pulse, respirations, blood pressure and O2 saturations. Tina’s vital signs were 128/82 blood pressure, 78 pulse, 99.0 temperature, 15 respirations per minute and 99% room air. The body’s temperature’s normal limits are 97.7F – 99.5F, this is done to ensure that the patient is not hypothermic or hyperthermia. The pulse is obtained to ensure that the heart rate and rhythm are regular which is 60-100 beats/min and abnormal findings would tachycardia, bradycardia or irregular rate. The respirations should be 12-20 breaths/min and respirations are relaxed , smooth and effortless this is to patient does not have bradypnea, tachypnea, hyperventilation, and apnea. The blood pressure is see if the patient has abnormal findings of hypertension or hypotension. Then an orthostatic blood pressure is taken to see if the patient’s blood pressure drops going from a sitting to standing position. Oxygen saturations should be 92%-100% and not less than 92% (Jensen 2015).
The health risks that came across with my assessment with Tina were: Tina is under the impression that since she is on the birth control pill then that’s all the protection she needs from acquiring any diseases from her sex partner. Rational is that condoms need to be used every time because they mostly provide the protection against sexually transmitted infections. (Jensen, 2015) According to the CDC, NIH, and all of the leading medical associations in this country, condoms are highly effective in preventing HIV infection and reduce the risk of pregnancy and a number of sexually transmitted infections. (Davis, 2008)
Contraceptive use does not protect against STI’s but only for preventative pregnancies. (Jensen, 2015) Oral contraceptives are amongst the most popular drugs, at present about 60 million women are using this highly effective form of contraception. (Jensen 2015). Tina does not perform self-breast exams. To optimize health maintenance, women should familiarize themselves at a young age with how their breasts normally feel to detect even slight changes. Women who perform SBE are more likely to discover cancer at an earlier stage. (Jensen, 2015).
During the interview Tina had stated that her diet has greatly improved, she mentioned that she drinks two diet cokes a day along with maybe 1-2 glasses of water a day. She will also have a diet coke with rum when she is out with her friends which maybe a few times a week. So, on top of her daily intake of diet coke then possibly having more later in the day along with liquor (another product of sugar) puts her at risk for her diabetes. Three recent studies suggest all diet sodas, not just diet coke lead to a number of poor health conditions, particularly for diabetics. ( ) According to American Diabetes Association, at least daily consumption of diet soda was associated with a 36% greater relative risk of incident metabolic syndrome and a 67% greater relative risk of incident type 2 diabetes compared with non-consumption (Jacobs, Lima, Lutsy, Michos, Nettleton, Wang 2009). Diet soda consumption, either independently or in conjunction with other dietary and lifestyle behaviors, may lead to weight gain, impaired glucose control, and eventual diabetes (Jacobs, Lima, Lutsy, Michos, Nettleton, Wang 2009). Tina is encouraged to increase her water intake and reduce her diet coke intake.
Tina plans on taking a trip to Puerto Rico with friends in a few months. There are definitely risks for visiting other countries. For Puerto Rico health risks are the mosquitos (Deane 2017). They are a nuisance all over the tropics. The mosquitos have been known in the past to transmit the Dengue fever, it has been reported by the CDC as a leading cause of death in the islands. (Deane 2017). Puerto Rico has had many cases and has even affirmed dengue epidemics in the past. The best protection against this fever is to wear sunscreen, mosquito repellent and long-sleeve shirts and pants. (Deane 2017). However, on land, your biggest opponent is when you get out of urban areas there is a chance of running into wild dogs and mongooses (Deane 2017). The last possible risk is that the CDC advises you to stay away from tap water, fountain drinks, and ice cubes. They also tell you not to eat food purchased from street vendors (Deane 2017).
While performing the Monofilament Test with Tina it was found that she had only had feeling on her bilateral heels. Anywhere on both forefeet was not felt. This can be an indicator of possible peripheral neuropathy which is a loss of feeling. To test this a calibrated, single-fiber nylon threads touch the bottom of feet to see if patient feels it or not. In Tina’s case she only felt it on her heels (Bindels, Dros, Van Weert, Wewerinke 2009). The sole purpose of a monofilament test is to diagnose peripheral neuropathy but is not recommended. (Bindels, Dros, Van Weert, Wewerinke 2009). The diagnosis of peripheral neuropathy should be made only after a careful clinical examination with more than 1 test, as recommended by the American Diabetes Association. (Bindels, Dros, Van Weert, Wewerinke 2009).
Tina’s healthy behaviors that were found during assessment was that she has started eating much healthier, instead of fast food she has found certain a certain diet and has found a way to make vegetables taste better. She feels much better and her blood glucose is within normal limits and now she checks it weekly.
Spiritually Tina seems better too. She is excited to start this new job and is looking further down the road to excel in her position and hopefully move up in her job. She is eager to learn her new position. She has also completed school and received her B.A. degree. She states that she has more time on her hands which allows her to find time to work out 4-5 days a week and swim one day a week. Tina has also lost about 10 pounds within the last 90 days. She has been to the dentist for cleanings and the optomologist and is currently wearing glasses which helps with her vision.
An intervention for the Integumentary system is for impaired skin integrity. Tina suffers from acne since she was young. She is counting on the conceptive medication to hopefully clear it. She should see a dermatologist for proper treatment. Patients with acne can become so concerned about their appearance that they can develop body dysmorphia (Schofield et al, 2009). Tina will be provided effective support the impact of the disease, whether Tina would be able to adhere to the suggested treatment; Tina’s understanding of the treatment and possible side effects and her motivation and expectations of treatment (Lavers, 2013).
For Tina’s respiratory system, her condition of asthma, the intervention for ineffective breathing pattern would be to decrease workload of breathing, pace activity and provide rest (Jensen, 2015). Also, Tina should have her home she lives in now and when she moves out of her mother’s house should have the house checked for mold for the well-being of Tina and her family (Frain, Glorennec, Le Bot, Le Cann, Paulus 2017).
Since Tina is starting a new job and will be moving out and this could lead to an increase in her blood pressure related to stress (Cardiac Health 2018). So, for Tina’s cardiovascular system the interventions for would be the patient’s life stressors, assessing the Tina’s current coping strategies, helping Tina identify and plan for her new lifestyle changes, and to continue to have encouraging positive thinking (Cardiac Health 2018).
For Tina’s gastrointestinal system, the intervention would be to determine Tina’s current eating patterns, she states that her diet has been better but continues to drink 2 diet cokes a day. Tina will then document her daily intake, when and where she eats. A daily meal plan will be developed to ensure a well-balance diet to reduce fats and calories. This will help with her diabetes as well. Tina will be encouraged to continue with her exercise routine.
As Tina continues to exercise, interventions will be put into place to prevent and reduce the impact of injuries and pain. (Derrett, Harcombe, McNoe, Richardson 2018). Tina will document her daily routine of what she actually includes in her exercise. She will also need to document the duration and intensity. This will measure the prevalence of injuries. Tina is encouraged to set up an appointment with a personal trainer that way she can make sure she will be free of injury (Derrett, Harcombe, McNoe, Richardson 2018).
When the monofilament test was performed, Tina was unable to feel sensation to bilat forefeet. Interventions for this would be for Tina to see a neurologist to follow up with more testing to determine if there is permanent damage to her feet which is most likely caused by her diabetes. Interventions will be to continue to have better control of her blood glucose and to change her diet habits with the diet cokes.
Interventions for Tina with having unprotected sex is to educate Tina what the risk factors for, causes of and ways to prevent STIs. Offer a variety of options for safe sex practices to provide choices. Also, that she is able to state the disease process, treatment effects, and side effects of the treatment (Jensen 2015).
Analysis Overall Plan
The overall plan for Tina is to start seeing a dermatologist for acne control to avoid scarring to her face and to rule out infection. Then Tina needs to be seen by a neurologist for the loss of sensation to her both her feet at the forefoot area. And if Tina can reduce her daily diet coke intake then maybe it is not too late for her to retrieve sensation back to her feet. A personal trainer would be ideal for Tina to put a plan together for her to avoid any injuries that she may sustain from exercising incorrectly. Tina will need to see a gynecologist for educational purposes and to test for STIs due to past history of unprotected sex.
The health risk that will be chosen for the teaching tool would be that Tina is having unprotected sex and is under the impression that since she is on the pill that is all the protection she needs. The reason why this health risk was chosen was because having unprotected sex and multiple sex partners puts you at higher risk for STIs. Many STIs can have no symptoms when you are first infected and makes having unprotected sex so dangerous because you may have an infection without knowing it then transmitting it to someone else.
The goal is to empower Tina with information about unprotected sex. The goal is for Tina to demonstrate knowledge of the risks of sexual activity, including how sexually transmitted infections are spread. She will also be able to identify multiple sexually transmitted infections, including their symptoms and treatments. Then she can demonstrate knowledge of different practices and strategies for preventing sexually transmitted infections. The last goal would be for Tina to demonstrate the ability in making decisions about her sexual health choices.
STIs is a significant health concern, and it is even further increased by their contribution to HIV transmission. According to some estimates, both ulcerative and nonulcerative STIs increase HIV transmission risks as much as 3- to 5-fold (Kirby 2002). STIs are transmitted by unprotected sex that can also lead to HIV transmission which can cause serious health issues including death. (Kirby 2002). Many HIV-infected adolescents and young adults have not been tested for HIV so then their HIV status is not known, and also because of the typically long time period before the beginning of clinical AIDS, many cases of the HIV/AIDS that are identified among people in their 20s or early 30s could have been acquired during their teen years and in their early 20s (Kirby 2002).
There are multiple interventions that can be put into place. First, they suggest that there should be effective HIV education programs for all young people. They also suggest that there should be additional, more focused programs for those groups of adolescents who are at higher risk of HIV infection (Kirby 2002). Educational programs for school-aged males should address the risks of unprotected intercourse among males who may have sex with males, while programs for young women and female adolescents in the United States should address the special threat of unprotected heterosexual intercourse (Kirby 2002). Condoms are recognized as an especially important form of contraception, because they are the only form of contraception that helps prevent the transmission of most STIs (Kirby 2002). Also, sex, STD, and HIV education programs have been implemented in multiple settings which are schools, family planning clinics, STI clinics, churches, youth serving agencies, housing projects, homeless shelters, detention centers, and communities more broadly (Kirby 2002).
It seems that male teens attending an STI clinic that received either a 14-minute video, or a one-on-one session with a health care educator. Male teens received the results of their STI tests and an appropriate treatment if needed. The education that seemed to be most effective was providing modeling along with practice with communication, negotiation, and refusal skills. There are significant variations in the quality of activities that are designed to teach skills and also in the time devoted to practicing the skills (Kirby 2002).
These programs are able to help reduce HIV transmission among youth by supporting the adoption of programs that hold promise for reducing adolescent unprotected sex–especially those programs identified as effective–and by encouraging the development, evaluation, and replication of programs specifically designed for adolescents who engage in particularly high-risk sexual activities.
I chose this health risk because Tina has had multiple sex partners but through assessment it seemed to me that when I asked her if she uses protection with sex she stated yes because she is on the birth control and did not mention condoms. If she continues to have unprotected sex with others and have not been tested for STIs she could be spreading diseases and infecting many more. If any or all of the effective programs are implemented more broadly, they can have a modest impact upon reducing adolescent sexual risk-taking behavior (Kirby 2002). Some of the most effective programs reduced sexual risk taking by roughly a third over an extended period of time. To the extent that these programs reduce sexual risk-taking behavior, then logically they should also reduce STD and HIV transmission (Kirby 2002).