oniphas homewoek

7/29/2019 oniphas homewoek

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Name: Onipha Tappin

Date: 31/10/12

Teacher: Sis Francis

Subject: Health Assessment

HEALTH ASSESSMENT


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Introduction

In this project you will find all the information required in the care of the client in order

to give proper care and treatment. I hope you find it informative and helpful.

Health Assessment: a plan of care that identifies the specific needs of the client and

how those needs will be addressed by the health care team.

Chalazion: a small bump in the eyelid caused by a blockage of a tiny oil gland.


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Table of ContentsIntroduction.1

Biographical Data2

Chief Complaint3

History of Current Illness...3

Past Health History..3-4

Current Health Status..4

Family History..4

Psychosocial History...5

Neurological Assessment.6

Respiratory Assessment...6

Cardiovascular Assessment...6

Gastrointestinal Assessment.6

Genitourinary Assessment.6

Musculoskeletal Assessment6

Skin, head/neck, eye, ears, nose, mouth/ throat, breast.7

Head-to-Toe Assessment8-10

Medical Diagnosis/Order11

Needs/Problems of the Client.11

Care Plan12-15


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Biographical Data

Name: Adrean N Jones

Sex: Female

D.O.B: 10/09/87

Age: 25 years

Address: Golden Grove New Extension

Contact #: Tel: 560-3695 Cell: 724-9198

Country of Birth: Guyana

Nationality: Guyanese

Religion: Moravian

Race: Black

Place of Employment: Cedar Hall Moravian Pre-School Tel: 464-5577

Occupation: Teacher

Marital Status: Engaged

Next of Kin: Cadeem Browne Relationship: Fianc Tel: 770-4514

Address: Golden Grove New Extension

Medical Insurance: yes Company: Sagicor

Family physician: Dr Moulon

The source of information is reliable

Informant: Adrean Jones


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Subjective Data

Chief Complaint

Bump on eyelid for 14/52, it is swollen and painful.

History of current illness

Last well until two weeks ago, on waking client observed swelling of right upper eyelid.The following morning on examination the client felt a large bump, painful to touch. Cold

compresses were applied with no improvement. It is accompanied with photophobia,

excessive tearing, eye pain and heaviness of the lid. Last eye examination 6 years ago.

First episode of condition. Client wears glasses daily for near sightedness treatment. No

history of blurred vision, eye injury, double vision, cataracts or glaucoma, eye surgery,

retinaldetachment, strabismus, or amblyopia, loss of vision or parts of fields. Client

unable to read for long periods of time due to fatigue of the affected eye.

Past Health History

Childhood Illnesses: Nohistory of mumps, mumps, chickenpox, rubella, frequentear infections, frequentstreptococcal infections or sore throats, rheumatic fever,

scarlet fever, pertussis,or asthma.

Accidents/Injuries: Broken arm from fall at age 7, treated and released fromGeorgetown Hospital. Ingestion of foreign object (marble) at age 7, admitted to

Holbderton Hospital x14/52, treated and released. Dislocated thumb at age 12

treated and released from Holberton Hospital.

Obstetric History: Nulliparous


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Immunization:All childhood vaccinations received measles, mumps,rubella, chickenpox, hepatitis B, diphtheria, polio. Tetanus 2

ndbooster to be

received.

Hospitalizations:At age 7 for 14 days to monitor progress of ingested object. Last Examination: Secondary school physical in 1stform. Last dental exam at

age 15years. Eye exam for glasses at age 16years.

Allergies: No known allergies. Current Medications: Birth control pills Microgynon 1/day since April 24th, 2012.

Current health status

General health is OK. No changes in appetite or weight. Able to perform ADLs without

difficulty. No history of weakness, unexplained fevers, or unusual symptoms.

Family History

Father has had similar eye problems in the past. Maternal grandfather died at age 81 years due to complications of

hypertension.

Maternal aunt has seizure disorder. High blood present in maternal grandmother, maternal uncle and

maternal aunt.

No history of heart disease, cancer, diabetes, tuberculosis, stroke, bleedingdisorders.


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Psychological History

Self-concept

Completed all stages of education from primary to college to teachers training.

Works at the Cedar Hall Moravian Pre-School as a teacher, describes it as a fun

and fulfilling job. Believes in God but does not attend church. Believes self to be

loving, kind and dependable.

Lifestyle

No smoking, drinks on special occasions such as carnival and Christmas, one to

two beers.

Diet- Does not eat breakfast, and sometimes skips meals. Believes nutritional

status is adequate but could be better, such as eating 3 square meals, and a more

balanced diet.

Exercise- Does not have a set exercise program but takes regular walks with

fianc.

Psychosocial- Has a good relationship with friends, family, partner and co-workers. Lives in a two bedroom one bath home with partner and 5 dogs.

Describes life as happy but stressful sometimes due to long work hours. This she

copes with by finding a quiet place to read a good book and relax and talking

problems over with partner or sisters.

Economic- Believes economic status is adequate but could be better in ways of

savings.


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Review of Systems Neurological: No history of fainting, seizures, lossof consciousness, head

injuries, changes in cognition or memory, hallucinations, disorientation, speech

problems, sensory disorientation such as numbness, tingling or loss of sensations,

motor problems, problems with gait, balance or coordination. No impact on ADLs.

Respiratory: No history of breathing problems, cough, bloody sputum, SOBwith activity, wheezing, pneumonia, bronchitis or tuberculosis. Last chest x-ray

was 18 years ago to note progresses of ingested object, no abnormalities noted.

Cardiovascular: No history of chest pain, palpitations, murmurs, skippedbeats, hypertension, awakening at night with SOB, dizzy spells, cold hand or feet,

colour changes in hands and feet, pain in the legs while walking, swelling of the

extremities, hair loss on legs, poor wound healing. Has never done an EKG.

Gastrointestinal: No history of loss of appetite, indigestion, heartburn,nausea, vomiting, liver or gallbladder disease, jaundices, changes in bowel

patterns; colour of stool, constipation or diarrhoea, hemorroids, weight changes

(loss or gain), use of laxatives and acids.

Genitourinary: No history of pain on urination, burning, urgency, dribbling,incontinence, hesitancy, changes in urine stream or colour, no history of urinary

tract infections, kidney infections, kidney disease, kidney stones, or frequenturination at night.

Musculoskeletal: History of fractures. No history of sprains, muscle cramps,pain, weakness, noise with movement, spinal deformities, low back pain, loss of

height, osteoporosis, degenerative joint disease, or rheumatoid arthritis.


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Nose: Symmetrical. No deformities or tenderness on palpation. Nares patent.Mucosa pink, no lesions. Septum midline, no perforation. No sinus tenderness.

Mouth: Mucosa and gums pink, no lesions or bleeding. Slight yellowing to teethnoted, no cavities present. Tongue symmetric, protrudes midline. Uvula rises

midline. Gag reflex present.

Neck: Symmetric, no masses, tenderness. Trachea midline. Thyroid nonpalpable,not tender. Neck supple with full ROM.

Spine and Back: Normal alignment of spine, no deformities noted. Notenderness on palpation.

Thorax and Lungs: Equal bilateral chest expansion. Breath sounds audible.Diaphragmatic excursion equal bilaterally. Lungs field clear with no adventitious

sounds.

Breasts: Symmetric, no discharge or lesions. No masses or tenderness onpalpation.

Heart: No pulsations, lifts or heaves. Heart sounds normal, no murmurs or thrillspresent.

Abdomen: Flat, symmetric. Skin smooth with no lesions, scars or striae. Bowelsounds present, no bruits. Abdomen soft, no organomegaly.

Musculoskeletal: Colour distribution on extremities equal, no deformities orlesions. No tenderness. All peripheral pulses present and equal bilaterally. Full

ROM present. No tenderness or weakness in joints. Muscle strength able to

maintain flexion against resistance and without tenderness.


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Neurologic: Alert and oriented to person place and time. Thought coherent.Remote and recent memories intact. Cranial nerves ii through xii intact. Sensory,

pin prick, light touch intact. Able to identify objects. No atrophy, weakness or

tremors. No gait abnormalities, able to tandem walk. Cerebellar, finger to nose

smoothly intact.


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Medical Diagnosis/ Order

Based on the symptoms a diagnosis of a Chalazion was made. Due to the size being so

small no surgery is required. To treat this condition a topical antibiotic eye drop is

prescribed, Chloramphenicol. The patient is also advised to apply warm compresses for

10-15 minutes four times a day. If bump continues to grow after a month return for

further analysis.

Needs of the Client

Pain relief knowledge


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Care Plan

Assessment Nursing

Diagnosis

Goal Interventions Outcome

criteria

Swollen, red,

painful, upper

eyelid with

bump and

light sensitivity

Altered

comfort (pain)

related to

inflammatory

process

evidenced by

client

verbalizing

pain.

Client will

verbalize a

reduction in

pain

-Advise the client to

apply warm

compresses for 10-

15 mins four times

daily. This is to aid in

reducing the swelling

and clearing the

blocked oil gland.

-Encourage the client

to wear sunglasses

in brightly lit places,

this decreases

discomfort from light

sensitivity.

-

Client will be

free of pain

while

receiving

treatment or

verbalize a

reduction in

pain.


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Knowledge

deficit related

to condition

evidenced by

client

verbalizing

incorrect

beliefs.

Client will

have

adequate

knowledge

related to

condition

evidenced by

clients

verbalizing

-Administer

prescribed

antibiotics

prophylactically as

this aids in the quick

resolution of the

condition thus to

relieve discomfort.

-Advise the client on

the need to monitor

for and changes in

the condition, as this

denotes a resolution

or progression of the

condition.

-Have the client

state their beliefs

and views on the

condition and its

cause, this is to note

where they need

further information

and correction.

-Client

verbalizes

correct and

accurate

information

about the

condition


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correct

information-Provide a quiet

environment

conducive to sharing

of information. This

is so that the client

feels that the nurse

is giving them

adequate attention

and allows them to

freely voice their

problems.

-explain to the client

the cause of the

condition the care

necessary and

preventative

methods to avoid

reoccurrence. Thisenables them to

better understand

the condition and

take precautions

against it.

-provide pamphletsto the client on the

condition so that

they have a source

of vital and correct

information.


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-For further

information to the

client ask the doctor

to converse with the

client so they can

further understand

the condition.


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