Comprehensive health assessment.

Final Project The Final Project (6-8 page paper) synthesizes the previous weeks’ study of advanced physical assessment by conducting a comprehensive assessment in ShadowHealth. The final project synthesis is focused upon designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan. Assessment of competency is based on the Comprehensive Patient Interview, Physical Examination and Individualized Plan of Care incorporating Healthy People 2020 and evidence-based interventions and patient-centered goals. You will use one comprehensive digital clinical experience health history and physical assessment for this assignment: Comprehensive Assessment. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. The use of Headers in your paper is strongly encouraged. Submission Parameters: For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 6-8 pages, which does not include the cover page and reference page(s). Introduction (including purpose statement) Subjective Findings Synthesis Objective Findings Synthesis Plan of Care Apply one nursing theory in planning care for this patient Incorporate Healthy People 2020 Objectives into the plan of care prioritized to meet the health needs of the patient Document evidence to support clinical reasoning for selected evidence-based plan of care Plan of care is individualized to findings, life-span stage of development with culturally specific considerations, and patient-centered. Conclusion References (use primary and/or reliable electronic sources) In regards to APA format, please use the following as a guide: Include a cover page and running head (this is not part of the 6-8 pages limit) Include transitions in your paper (i.e. headings or subheadings) Use in-text references throughout the paper Use double space, 12 point Times New Roman font Apply appropriate spelling, grammar, and organization Include a reference list (this is not part of the 6-8 pages limit) Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP) The Final Project documentation is due in Week Seven. Please see the Final Project below to help you complete the assignment.

Comprehensive Health Assessment.

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Ms. Jones is a 28-year-old who has an African-American ethnicity. She has visited the clinic to seek a complete health assessment, which is a requirement before securing her new employment. This paper will present the key findings of Ms. Jones’ comprehensive assessment. The findings will guide the development of an individualized and evidence-based plan of care to promote patient’s health through education and counseling. The self-care nursing model by Dorothea Orem and Health People 2020 will be considered during the formulation of the plan of care.Comprehensive health assessment.

Synthesis of Subjective Data

Chief Complaint (CC): “I came in because I’m required to have a recent physical exam for the health insurance at my new job.”

Health History

Current Health Status

Ms. Jones has secured a new job at the Smith, Stevens, Stewart, Silver, and Company. A pre-employment physical examination is required to allow the company to issue her with health insurance. She had visited Shadow Health Clinic four months ago for her annual gynecologist exam. Ms. Jones was diagnosed with the polycystic ovarian syndrome (PCOS) during the clinic visit. Consequently, the gynecologist prescribed her oral contraceptives, which have demonstrated a high degree of efficacy. She was previously diagnosed with type 2diabetes, which is managed through metformin medication and a healthy lifestyle, including taking a balanced diet and exercising regularly. The client has been taking metformin medication in the past five months and has not reported any side effects. She describes her health status as generally good. She also claims to be in a better position to take care of herself than in the past. As a result, she is ready for the new job at the Smith, Stevens, Stewart, Silver, and Company.Comprehensive health assessment.

Allergies: Ms.  Jones reports various allergic reactions. Penicillin causes a rash. She is also allergic to dust and cats. However, she denies food and latex allergies. She experiences multiple symptoms, including runny nose, and itchy and swollen eyes upon being exposed to allergens. Additionally, her asthma symptoms worsen. She manages these allergic reactions by moving from the place with the allergens, bathing, or using a resue inhaler. Comprehensive health assessment.

Medications: The client is currently taking different medications to manage various illnesses.

1. Fluticasone propionate, 110 mcg 2 puffs BID, which she used last this morning.
2. Metformin, 850 mg PO BID that was used for the last time in the morning.
3. Drospirenone and Ethinyl estradiol PO QD that she used for the last time in the morning.
4. Albuterol 90 mcg/spray MDI 2 puffs Q4H prn that she used for the last time three months ago.
5. Acetaminophen 500-1000 mg PO prn, which she uses any time she has a headache.
6. Ibuprofen 600 mg PO TID prn that she uses to manage menstrual cramps. She used it for the last time 6 weeks ago.

Medical History

The client was diagnosed with asthma at the age of 2 ½ years. The asthma symptoms worsen upon being exposed to triggers in particular upon being around a cat. She uses an albuterol inhaler in the event of an asthma exacerbation. She experienced the last asthma attack three months ago. She used her inhaler to manage the situation. The last hospitalization due to asthma was when she was in high school. Nonetheless, the client has never been intubated. Secondly, she was diagnosed with type 2diabetes at the age of 24. She started used metformin medication to manage her blood-sugar levels 5 months ago. She monitors her blood sugar levels every morning. Her readings range at around 90. Furthermore, Ms. Jones has a history of hypertension that normalized following lifestyle modifications, including taking a healthy diet and exercising regularly. She denies any surgeries. She had her first sexual encounter when she was 18 years old. Her sexual partners were heterosexual. She has never been pregnant. She had her last menstrual period in the previous 2 weeks. Ms. Jones was also diagnosed with PCOS in the last four months. The client reports a new male relationship although no sex has been initiated. She anticipates using condoms during sexual intercourse.Comprehensive health assessment.

Health Maintenance

Ms. Jones undertakes various activities to maintain her health. Her last pap smear test was performed in the past four months. She also had her last eye and dental exam three and five months ago, respectively. She also received tetanus in the previous years. However, she claims that her influenza is not current. She denies receiving human papillomavirus. She claims that her childhood vaccines are up to date. She observes some precautionary measures, including installing a smoke detector in her home, not riding a bike, and wearing a seatbelt in a car.Comprehensive health assessment.

Family History

Her 50-years old mother has a history of hypertension and high levels of cholesterol. Her father died of complications associated with diabetes, high blood pressure, and elevated cholesterol at the age of 58 years. Her brother has obesity while her sister has asthma.

Social History

Ms. Jones has never been married and has no children. However, she has a boyfriend. She claims to be a social drinker where she drinks when she is out with friends 2-3 times monthly. She denies using any drugs, including cocaine, cannabis, tobacco, and heroin.Comprehensive health assessment.

Review of Systems

General: She seems to be comfortable throughout the interview. She claims to be doing fine. She does not complain of any current illness. She is smartly dressed and presentable.

Vitals:  Height 170 cm., Weight 84 kg., BMI 29., BP 128/82., HR 78., RR 15 02 99%., Temp 37.2 C.

HEENT: The clients report no vision change, headache, or itchy or painful eyes. Denies sneezing or a runny rose. Hearing difficulty or ear pain was also denied.

Respiratory: No breathing difficulty or shortness of breath. No cough, runny nose, or sneezing.

Cardiovascular: No palpitations or chest pain.

Abdominal: No vomiting, diarrhea, or constipation.

Musculoskeletal: No muscle pain.

Neurological: No tingling or dizziness.

Skin, hair, and nails: She reports improvement in her acne following the use of contraceptives. Reports abnormal hair growth.Comprehensive health assessment.

Synthesis of Objective Data

Physical Examination

HEENT: Physical examination reveals that the head is normocephalic with no tenderness of the scalp or lesions. The bilateral of her vision was 20/20 with corrective lenses. Mild retinopathic changes were observed in the right eye. Nasal cavities were pink and no discharge was observed. The ear canal was also pink. Discoloration on her neck.Comprehensive health assessment.

Respiratory: Both chest walls are symmetric. Breath sounds present. No deformities or lesions.

Tests

Monofilament: Performed to evaluate the loss of protective sensation. Revealed a reduced sensation in her feet.

Abnormal Findings

Ms. Jones’ health history and physical examination revealed some abnormal findings. First, the physical examination reveals that Ms. is overweight and is likely to become obese. Additionally, Ms. Jones has a high probability of becoming obese due to the history of this lifestyle illness in her family. Both her parents had a history of elevated cholesterol. According to Srivastava et al. (2015), genes are among the major contributory factors for obesity. Also, her chances of becoming obese are high due to other factors such as ethnicity and gender. Being an African American, she much likely to become obese. The rates of obesity in the US are higher among African-American women compared to that of women from other ethnic groups. Obesity or overweight is reported in approximately 4 out of 5 African American women in the US (Petersen et al., 2015).Comprehensive health assessment.

Secondly, the monofilament test revealed a reduced sensation in her feet, which is a sign of peripheral neuropathy. Being diabetic, the client is at the risk of developing this condition. Diabetic neuropathy is the most common complication among individuals diagnosed with diabetes (Pop-Busui et al., 2017). More so, mild retinopathic changes were observed in the right eye during physical examination. Her diabetes is responsible for retinopathy. This condition is caused by damaging the blood vessels of the light-sensitive tissue that are located at the retina. Diabetic retinopathy is in its early stages since only mild symptoms are observed. However, it leads to blindness if not managed on time. According to Nentwich and Ulbig (2015), diabetic retinopathy is the primary cause of blindness in the working-age population in the US.Comprehensive health assessment. Discoloration on her neck was another abnormal finding. The hyperpigmented plaques on the skin signify acanthosis nigricans. This condition, which affects the level of hormones in the body is mainly caused by being overweight and type 2 diabetes (Ng, 2017). Therefore, Ms. Jones is at a higher risk of developing this condition since she has a history of diabetes and her BMI indicates that she is overweight. Also, Ms. Jones has abnormal hair growth in various parts of her body, including the face. This condition is mainly caused by Polycystic ovary syndrome (PCOS), which she was previously diagnosed with. PCOS is one of the major hormone disorders that is mainly characterized by the excessive growth of hair in the face and other body parts (Setji & Brown, 2014). Finally, Ms. Jones has pustules on her face, which portrays acne vulgaris. According to Chen et al. (2019), acne vulgaris is the most common skin disease among young people. Thus, being 28-year-old Ms. Jones is at a higher risk of developing this skin condition. Ms. Jones’ medical history and assessment findings necessitate the development of a plan of care.Comprehensive health assessment.

Plan of Care

Self- care enables patients to improve and maintain their health status, thus reducing symptoms of a particular illness or recovering completely. According to the self-care nursing model that was developed by Dorothea Orem, individuals are supposed to be self-reliant and in charge of their care (Sagar, 2017). Additionally, nurse practitioners are responsible for improving individuals’ health status. They should point out an area that requires self-care and guide and educate patients on how to boost the quality of life. Healthy People 2020 entails goals and objectives that advocate for the prevention of diseases and health promotion. Ms. Jones’ assessment findings indicate various health issues that required proper medical attention. Healthy People 2020 should be considered while developing her treatment plan. Additionally, the plan for care should educate, guide, and support the client in her self-care and health promotion efforts.Comprehensive health assessment.

First, Ms. Jones has already started being concerned about her health. Consequently, she has adopted some healthy practices, including taking a healthy diet, regular exercises, and avoiding stress. The level of cholesterol in the body is reduced by various therapeutic interventions, including the cessation of bad habits, taking cholesterol buster diets, and regular exercise (Harisa et al., 2016).Comprehensive health assessment. Therefore, taking a healthy diet with very little cholesterol and regular exercise will result in weight loss, thus preventing Ms. Jones from becoming obese. Diet and lifestyle modifications will also play a significant role in managing her diabetes. In addition to a healthy lifestyle and regular exercise, Ms. Jones has installed a smoke detector in the home to indicate the presence of smoke. This measure enables her to prevent the excessive level of smoke that might result in asthma exacerbations. The client should be encouraged to continue with these practices to improve and maintain her health status and overall quality of life. However, the client should be advised to stop taking alcohol. Consumption of alcohol increases the risk of multiple complications, including vascular diseases, cancer, and cardiovascular disease (Wood et al., 2018).Comprehensive health assessment.

Secondly, Ms. Jones should be educated about Continuous Blood Glucose Monitoring (CGM) to enable her to control her glycemic levels. According to Reddy et al. (2020), Continuous glucose monitoring (CGM) is highly effective and reliable in improving A1C among adult patients diagnosed with diabetes type 2. The CGM continuous glucose information will be availed by the CGM systems at an interval of five minutes. Approximately, Ms. Jones will receive 288 glucose readings daily (Chehregosha et al., 2019). These readings will improve her glycemic control and reduce hypoglycemia. Additionally, the CGM systems will allow Ms. Jones to evaluate the real-time effects of food and exercise on her blood glucose levels. Consequently, she will be able to monitor the possibility of hyperglycemia and hypoglycemia, thus avoiding potential dangers associated with their conditions.Comprehensive health assessment.

The client should also be educated about the importance of taking her current medications as prescribed. Specifically, she should continue taking the recommended dosage of fluticasone propionate, 110 mcg, which is 2 puffs., metformin, 850 mg PO BID, and Drospirenone and Ethinyl estradiol PO. According to Sanchez-Rangel and Inzucchi (2017), metformin, 850 mg is the primary treatment therapy for individuals diagnosed with type 2 diabetes. Strict adherence to the instructions will result in improved health and overall well-being.Comprehensive health assessment.

Finally, the client should be educated about reproductive health and family planning methods since she is currently in a new relationship. This education and guidance will enable the client to give birth at the appropriate time. Additionally, Ms. Jones should be educated about the importance of using protection during sexual intercourse to protect herself from sexually transmitted diseases. One of the major goals of Health People 2020 is to promote healthy sexual behaviors to prevent the spread of sexually transmitted diseases among citizens.Comprehensive health assessment.

Conclusion

Ms. Jones’ current health status, health issues, and health behaviors are revealed by her health history and physical examination. An individualized plan of care for Ms. Jones was developed based on the assessment findings, the primary goals of Healthy People 2020, and the self-care nursing model by Dorothea Orem. The plan would then promote Ms. Jones’ health through education, training, guidance.Comprehensive health assessment.

Nursing Care Plan: Diabetes Mellitus

The National Center for Chronic Disease Prevention and Health Promotion Division of Diabetes Translation reports that nearly 34.2 million Americans have been diagnosed with diabetes as of 2018. This is approximately 10.5% of the nation’s population. The number is expected to increase significantly by the end of the decade. It is because of the prevalence of this disease that nurses require to gain significant skill and knowledge when it comes to not only caring for patients but also educating them. Comprehensive health assessment.This will include preparing the appropriate nursing care plan for type 2 diabetes. Diabetes mellitus is a chronic metabolic disease characterized by abnormally high levels of blood glucose (Abduzhapparova, 2019). Symptoms of the condition include polydipsia, polyuria, fatigue, weight loss and blurred vision. Nursing care plans for a patient suffering from the above condition will include effective treatments to normalize the patient’s blood glucose, to reduce complications arising from insulin replacement, exercise and balance diet (Sun et al., 2016). It is the responsibility of the nurse to stress the importance of complying with all prescribed elements of a treatment program by effectively educating said patient. The nurse will need to tailor their teaching and treatment to the patient’s abilities, needs and developmental state as the case in this response will illustrate.Comprehensive health assessment.

Subjective Data

A 40 year old male patient presented to the emergency room. The patient explained that he has been experiencing extreme thirst, blurred vision and frequent urination for the previous three days after attending an office party. Since the day after the party, the patient has been vomiting. He states that he was diagnosed with diabetes mellitus from childhood. Despite knowing about the disease, the patient reports neglecting to check his sugar and only giving himself the prescribed insulin injections occasionally. Comprehensive health assessment.The patient also stated that the was under medication including; for his pain, the patient takes Lortab 10-325mg 1-2 Tabs every 6 hours as needed, Neurontin 300mg PO BID, Metformin 1000 mg PO BID and on occasion, the patient takes regular insulin per sliding scale during meals. The patient also stated having neglected to take Levemir 35 units subq at night for nearly two months.Comprehensive health assessment.

Objective Data

The patient’s vitals were as follows; Oxygen saturation was at 92%, blood pressure was 108/68, heart rate stood at 106 and RA 25.upion assessing the patient, it was apparent that his eyes were sunken, his skin turgor was greater than 3 seconds, his skin appeared flushed and dry, and his breath smelled fruity.Comprehensive health assessment.

Nursing Diagnosis

Following the patient’s lab work that showed K+ 2.9, Glucose 636 the conclusion was that the patient was experiencing electrolyte and fluid imbalance (Cárdenas-Valladolid, et al., 2018). v16).., arova, A. (2019).iet and excersise regimen for  the patient.t goals whichultimatelyimporove  nurse and patient.are aime

Nursing Outcomes

The Patient’s Blood glucose will within 24 hours be between 90 and 150 while his K+ levels will be between 3.5 and 5.0 within half that time. Before being discharged, the patient will express a number of long-term side effects stemming from unmanaged diabetes. The patient will also demonstrate to the registered nurse how he takes his sugar levels as well as how he administers insulin injections to himself. The above is according to Cárdenas-Valladolidet al., (2018).Comprehensive health assessment.

Plan of Care

As part of the care plan, nursing intervention will aim to ensure that the patient achieves blood glucose levels of less than 180mg/dl as well as an A₁C of less than 5.7. To achieve the above, several interventions will be undertaken. First the nurse will assess the patients for signs of hypoglycemia or hyperglycemia. This will aid in determining th4e correct treatment in maintaining the above mentioned blood glucose levels. Symptoms of hypoglycemia include fatigue, dizziness, headache, tachycardia, and diaphoresis. Those of hyperglycemia include polyuria, polyphagia, and polydipsia, blurred vision and fatigue (Sun et al., 2016). Based on the patient’s subjective data, it is evident that they are suffering from the latter.Comprehensive health assessment.

The nurse will need to monitor the patient’s blood glucose levels over the course of the care plan. The frequency of these checks will be heavily dependent on the length of the care plan. This will ensure that the patient’s blood glucose levels will remain within the specific range that was targeted (Cárdenas-Valladolid et al., 2018). The nurse will also be responsible for the administration of diabetic medication, both insulin therapy and oral as prescribed. This will be for the purposes of keeping the glucose levels of the patient within the normal range, thereby effectively controlling the patient’s disease and reducing their risk of damage to the blood vessels and nerves, kidney injury and other complications that are common with diabetes mellitus.Comprehensive health assessment.

The nurses will also need to encourage the patient to stick to their dietary plan. This will include low calories, low fat and foods high in fiber which are all ideal for patients with diabetes (DeGarmo, n.d). Finally, the nurse will ensure that the patient increases their physical activity especially aerobic exercise. Exercise will work to decrease the blood sugar levels because the demand for glucose in the cells will increase with physical activity (Cárdenas-Valladolid et al., 2018).Comprehensive health assessment.

Another important nursing diagnosis relates to imbalanced nutrition. This is as explained by the unexplained loss in weight, an increase in urinary output, and high glucose levels in the blood, weakness and fatigue. The desired dietary outcome will involve the patient being able to achieve a weight that is within his normal BMI range while demonstrating healthy choices and healthy eating habits. Interventions for this nursing diagnosis will include explaining to the patient that there is a relationship between diabetes and weight loss. This is according to Sun et al (2016).Comprehensive health assessment.

The above will ensure that the patient understands why unexplained weight loss is among the signs of diabetes. The nurse will also facilitate the creation of a daily food and fluid chart as well as a weight chart. They will discuss both the short and long-term goals of weight loss with the patient. The above intervention will allow for the effective monitoring the nutritional intake of the patient on a daily basis as well as the progress of their weight loss. The patient will receive assistance in selecting the correct dietary choices to follow on a low fat, high fiber diet. The nurse will refer the patient to a dietician who will be responsible for the provision of more specialized care for patients that are still learning how to manage their diabetes (DeGarmo, n.d). Comprehensive health assessment.

Nursing Theory

According to da Silva and Ferreira (2016), in the 1960s, Imogene King would develop The Theory of Goal Attainment. The theory contains the description of a dynamic interpersonal relationship in which patients such as the one described in this response grow and develop to attain their life and health goals. Comprehensive health assessment.This theory explains that the factors that may affect the patient’s attainment of their goals are stress, roles, time and space. This nursing theory has three systems that interact. These are the interpersonal, personal and social. All of the above systems contains its own set of concepts. In the personal system, the concepts are self, perception, development and growth, space, body image and time. In the interpersonal system, the concepts involved are transaction, communication, role, and also stress. Finally, in the social system, concepts include authority, organization, status, power and decision-making.Comprehensive health assessment.

Like many other nursing theories, the Theory of Goal Attainment has several propositions and assumptions. First, if perpetual interaction accuracy exists in any nurse-patient relationship, a series of transactions will occur. Secondly, the theory proposes that once a transaction is made between nurse and patient, the goals set by the two are achieved. Once the goals are achieved, both parties will be satisfied.Comprehensive health assessment.

According to the theory, transactions between nurse and patient work to enhance growth and development. Furthermore, if role performance and role expectations as perceived by the relevant parties are congruent, they will further enhance transactions between the two.  According to the theory, stress in the interaction between nurse and patient is a function of role conflict occurring on the part of either nurse or patient. Mutual goal setting is said to occur if a nurse who has special knowledge communicates the relevant information to a patient. The above is according to da Silva and Ferreira (2016).Comprehensive health assessment.

Apart from the above propositions, the theory also contains within it a number of assumptions. First the theory assumes that the focus of nursing is the care of the patient. It also assumes that the goal of all nurses is the healthcare of not only individuals but also groups. According to King, humans happen to be open systems that interact with their environment constantly.  The theory also assumes that nurse and patient endeavor to communicate and set goals together, followed by a mutual action towards the goal. This also happens to be the main assumption of the overall nursing process.Comprehensive health assessment.

This theory, when applied to the nursing care plan of the patient in question will emphasize the development of a nurse-patient relationship as a means of enhancing the achievements of the patient’s goals. The role of the nurse therefore is extended to the development of relationships with patients, communicating the relevant and appropriate information to them and ensuring that they achieve the goals set by both parties for the benefit of the patient and their health.Comprehensive health assessment.

Healthy People 2020 Objectives and the Plan of Care

One of the goals or objectives of Healthy People 2020 is the reduction of the disease burden from diabetes mellitus as well as to improve the quality of life of all individuals, such as the patient in question that either have the disease or are at risk of it (Silva et al., 2018). Of the objectives set by the Healthy People 2020 initiative, two of three objectives that address the behaviors to reduce the risk of developing this condition among individuals who have prediabetes would extend the targets while the third demonstrated no detectable change. The number of individuals who increased their physical activity would since the conception of the initiative increase from 44.6% to 54.7%, thereby exceeding the 2020 target (Gelvez, et al., 2018).Comprehensive health assessment.

The above objective is an integral part of the care plan within this response. The nursing care plan while bring redundant at eliminating the risk factors for diabetes for the patient, will work to improve his quality of life. By improving the patient’s adherence to medication, diet and physical exercise, the nursing care plan will sure the patient lives a life void of complications resulting from diabetes mellitus.Comprehensive health assessment.

According to Lee et al., (2017), telemedicine features greatly among the strategies that ensure that patients adhere to their care plans. It is important to note that while prescribe treatment regimens, educate patients and emphasize importance of quality life, little could be done when the patient was away from the healthcare facility. With telemedicine, nurses can ensure that patients are constantly reminded on the importance of their care plans within the convincing of their homes. Comprehensive health assessment.This has further been made true by the recent COVID19 pandemic where social contact was limited been between limited. Before the advent of telemedicine, some patients would have lost touch of their treatment regimens thereby increasing the risk of complications (Silva et al., 2018). The patient in question is a good example as he has expressed the fact that he has in the past failed to take his prescribed medication and monitor his blood sugar.Comprehensive health assessment.

Conclusion

Diabetes mellitus has proven to be one of the more prevalent diseases in the United States. Like the patient in question, many people diagnosed with the condition tend to neglect some of the recommended practices that are aimed at improving their quality of life. Comprehensive health assessment.These include taking their medication as prescribed, eating balanced meals and exercising. Regardless of this, nursing care interventions need to be both wholesome and should involve a partnership between nurse and patient. As the above mentioned Theory of Goal Attainment has illustrated, such partnerships allow for the achievement of patient goals which ultimately improve their quality of life (da Silva and Ferreira 2016). It is worth noting that the above care plan has an interdisciplinary element. Nurses will be in charge of partnering patients with other professionals such as nutritionists and physical therapists to prescribe the relevant plans to ensure a healthy diet and exercise regimen for the patient.Comprehensive health assessment.