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    Name: Onipha Tappin

    Date: 31/10/12

    Teacher: Sis Francis

    Subject: Health Assessment


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    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


    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


    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


    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.


    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


    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


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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


    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


    Goal Interventions Outcome


    Swollen, red,

    painful, upper

    eyelid with

    bump and

    light sensitivity


    comfort (pain)

    related to



    evidenced by




    Client will

    verbalize a

    reduction in


    -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



    Client will be

    free of pain



    treatment or

    verbalize a

    reduction in


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    deficit related

    to condition

    evidenced by





    Client will




    related to


    evidenced by






    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


    -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.



    correct and



    about the


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    information-Provide a quiet


    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


    -explain to the client

    the cause of the

    condition the care

    necessary and


    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


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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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