The topic this week asks you to apply what you have learned to the following case study.

As the school nurse working in a college health clinic, you see many opportunities to promote health. Maria is a 40-year-old Hispanic who is in her second year of nursing school. She complains of a 14-pound weight gain since starting school and is afraid of what this will do to both her appearance and health if the trend continues. After conducting her history, you learn that she is an excellent cook and she and her family love to eat foods that reflect their Hispanic heritage. She is married with two school-age children. She attends class a total of 15 hours per week, plus she must be present for 12 hours of labs and clinical. She maintains the household essentially by herself and does all the shopping, cooking, cleaning, and chauffeuring of the children. She states that she is lucky to get 6 hours of sleep per night, but that is okay with her. She lives 1 hour from campus and commutes each day.

Using Healthy People 2020 and your text as a guide, answer the following questions.

1. What additional information would you like to gather from Maria?
2. What are Maria’s real and potential health risks?
3. Why is Maria’s culture important when obtaining the health assessment?
4. Pick one of Maria’s health risks. What would be one reasonable short-term goal for this risk?
5. What nursing interventions would you incorporate into Maria’s plan of care to assist her with meeting your chosen goal? Please provide rationale for your selections.

Using Healthy People 2020 and your text as a guide, answer the following questions.

1. What additional information would you like to gather from Maria?
2. What are Maria’s real and potential health risks?
3. Why is Maria’s culture important when obtaining the health assessment?
4. Pick one of Maria’s health risks. What would be one reasonable short-term goal for this risk?
5. What nursing interventions would you incorporate into Maria’s plan of care to assist her with meeting your chosen goal? Please provide rationale for your selections.  Physical and health assessment paper.

ADDITIONAL INFO 

Physical and health assessment

Introduction

The physical assessment is the first step in assessing a patient. It can be performed as part of your initial encounter with a new patient, or it can be done anytime during the course of treatment. During this procedure, you’ll look for signs that indicate health problems and respond accordingly.

Physical examination

The Physical Examination is a key part of the health assessment. This includes inspection of the general appearance, including skin and mucous membrane abnormalities; inspection of lymph nodes, lymphatic system and thorax; palpation (feeling) of bones, muscles and joints; percussion (touching lightly) over a number of organs as well as any abnormal findings on physical examination such as cardiac murmurs or ascites.

Assessment of vital signs

Vital signs are measurements of your physical condition that you can use to determine whether or not you need medical attention. A physician, nurse practitioner or other healthcare professional will perform a physical assessment during your visit. You may be asked to rate your pain level on a scale from zero (no pain) to 10 (worst possible pain).

The following is an example of a typical vital sign assessment:

Developmental assessment

Developmental assessment is the process of evaluating a child’s development at various ages. This can be done by observing, recording and analyzing information from both the parents and the child.

The main purpose of this type of assessment is to ensure that a child’s development is on track with his or her age group so that he or she does not fall behind in any way or form. It also allows teachers to make sure their students are ready for school when it comes time for them to enter kindergarten or first grade at elementary school level.

Neurological assessment

Neuropsychiatric assessment is the systematic examination of the nervous system. It is an important part of your physical and health assessment, as it helps you to determine how well your patient is able to function in his/her daily life.

When you are assessing neurological function, it’s important to focus on two main areas:

• Consciousness level – this includes their ability to follow commands regardless of whether they understand what they are doing at any given time (e.g., talking out loud) or not being able to perform simple tasks such as buttoning up a shirt or dressing themselves (this may be due to lack of adrenal glands).

• Cranial nerves and motor function – these aspects will help determine if there are any problems with movement or speech that may require further tests during your visit with them later on down the road if needed.*

Musculoskeletal assessment

The musculoskeletal assessment includes the following:

• Range of motion. Check for swelling, tenderness, deformities and masses. Look for skin changes and joint sounds.

• Muscle strength. Measure your grip strength with a hand dynamometer (a device that measures muscle power).

Cardiovascular assessment

• Listen to the heart.

• Listen to the lungs.

• Listen to the abdomen.

• Listen to the back and neck (and any other area of concern).

Respiratory assessment

Physical assessment of breath sounds and chest wall movement

The examiner should assess the ability to breathe normally, noting any abnormalities in each of these areas. The first thing that should be looked at is whether or not the person has enough air entering their lungs with each breath. He or she may have difficulty breathing because they are unable to expand their chest adequately, especially if there is swelling in the neck area and/or loss of elasticity in tissues around this region (e.g., due to coughing). If you see signs such as wheezing when you attempt to listen for breath sounds on your patient’s chest wall during physical examination, then this is another possible cause behind their lack of adequate ventilation during normal activities like talking or even walking upright — which can lead up towards more serious health issues down the road if left untreated!

Genitourinary assessment

You can also perform a genitourinary assessment on your patient. This is a physical exam of the genital area and should include checking for changes in the size, shape, color and texture of the testicles; any lumps or bumps in the groin area; changes in penis size including flaccidity (prolonged softness); pain when passing urine or having sex; discharge from any opening (e.g., urethra)

Gastrointestinal assessment

The gastrointestinal assessment is a comprehensive examination of the digestive system. It includes all aspects of the GI tract, including:

• Abdominal masses and distention

• A tenderness in the lower abdomen, which can be due to pregnancy, surgery or inflammatory bowel disease (IBD)

• Pain in the stomach and/or upper abdomen that may be related to any number of conditions, including pancreatitis or heartburn

The following tests are done during this part of your physical:

Dermatologic assessment

The dermatologic assessment is performed to assess the skin, hair, nails and mucous membranes. The following are examined during this evaluation:

• Skin color: The color of the skin is assessed by observing any pigmentary changes. Pale or blueish-gray skin may indicate hypothyroidism (low thyroid hormone levels).

• Temperature: This is measured using a rectal thermometer with an oral probe that measures core body temperature by inserting it into the anus, then taking readings when it’s inserted into different temperatures below 37 degrees Celsius (98.6 degrees Fahrenheit).

• Turgor/youthful appearance: The turgor or firmness of your skin can be determined by observing whether there’s any change in its appearance from one side to another or if there are fine wrinkles on either side of your face or neck area which may indicate signs aging effects such as dryness due to dehydration caused by lack hydration levels within cells which leads us back into our topic once again!

Conclusion

A physical exam can be a lot of fun, but it’s also a powerful tool for doctors to use when making decisions about their patients. If you have any questions or concerns about your health, don’t hesitate to schedule an appointment with your doctor as soon as possible.