Health Assessment
Health Assessment
| Course Code | Class Code | Assignment Title | Total Points | ||||||
| NUR-643E | NUR-643E-O500 | Health Assessment Check-Off Project | 75.0 | ||||||
| Criteria | Percentage | 1: Unsatisfactory (0.00%) | 2: Less Than Satisfactory (80.00%) | 3: Satisfactory (88.00%) | 4: Good (92.00%) | 5: Excellent (100.00%) | Comments | Points Earned | |
| Criteria | 100.0% | ||||||||
| Chief Complaint | 8.0% | A description of the chief complaint is not included. | A description of the chief complaint is incorrect or incomplete. | A description of the chief complaint is included but lacks details. | A description of the chief complaint is complete and lacks supporting details. | A description of the chief complaint is extremely thorough and includes substantial details. | |||
| History of Present Illness | 8.0% | A description of present history of illness is not included. | A description of present history of illness is incorrect or incomplete. | A description of present history of illness is included, but lacks details. | A description of the present history of illness is complete and lacks supporting details. | A description of the present history of illness is extremely thorough and includes substantial details. | |||
| Past Medical History (Hx) | 8.0% | A description of past medical history is not included. | A description of past medical history is incorrect or incomplete. | A description of past medical history is included, but lacks details. | A description of past medical history is complete and lacks supporting details. | A description of past medical history is extremely thorough and includes substantial details. | |||
| Past Surgical Hx | 8.0% | A description of past surgical history is not included. | A description of past surgical history is incorrect or incomplete. | A description of past surgical history is included, but lacks details. | A description of past surgical history is complete and lacks supporting details. | A description of past surgical history is extremely thorough and includes substantial details. | |||
| Family Hx | 8.0% | A description of family history is not included. | A description of family history is incorrect or incomplete. | A description of family history is included, but lacks details. | A description of family history is complete and lacks supporting details. | A description of family history is extremely thorough and includes substantial details. | |||
| Social Hx | 8.0% | A description of social history is not included. | A description of social history is incorrect or incomplete. | A description of social history is included, but lacks details. | A description of social history is complete and lacks supporting details. | A description of social history is extremely thorough and includes substantial details. | |||
| Allergies | 8.0% | A description of allergies is not included. | A description of allergies is incorrect or incomplete. | A description of allergies is included, but lacks details. | A description of allergies is complete and lacks supporting details. | A description of allergies is extremely thorough and includes substantial details. | |||
| Medications | 8.0% | A description of medications is not included. | A description of medications is incorrect or incomplete. | A description of medications is included, but lacks details. | A description of medications n is complete and lacks supporting details. | A description of medications is extremely thorough and includes substantial details. | |||
| Review of Symptoms by System | 8.0% | A review of symptoms by system is not included. | A review of symptoms by system is incorrect or incomplete. | A review of symptoms by system is included, but lacks details. | A review of symptoms by system is complete and lacks supporting details. | A review of symptoms by system is extremely thorough and includes substantial details. | |||
| Physical Exam | 8.0% | A description of the steps taken during the physical exam is not included. | A description of the steps taken during the physical exam is incorrect or incomplete. | A description of the steps taken during the physical exam is included, but lacks details. | A description of the steps taken during the physical exam is complete and lacks supporting details. | A description of the steps taken during the physical exam is extremely thorough and includes substantial details. | |||
| Assessment | 8.0% | A description of the assessment steps is not included. | A description of the assessment steps is incorrect or incomplete. | A description of the assessment steps is included, but lacks details. | A description of the assessment steps is complete and lacks supporting details. | A description of the assessment steps is extremely thorough and includes substantial details. | |||
| Treatment Plan | 8.0% | A description of the treatment plan recommended for the patient is not included. | A description of the treatment plan recommended for the patient is incorrect or incomplete. | A description of the treatment plan recommended for the patient is included, but lacks details. | A description of the treatment plan recommended for the patient is complete and lacks supporting details. | A description of the treatment plan recommended for the patient is extremely thorough and includes substantial details. | |||
| Mechanics of Writing (includes spelling, punctuation, grammar, and language use) | 2.0% | Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is employed. | Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied. | Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed. | Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech. | The writer is clearly in command of standard, written, academic English. | |||
| Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) | 2.0% | Sources are not documented. | Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors. | Sources are documented, as appropriate to assignment and style, although some formatting errors may be present. | Sources are documented, as appropriate to assignment and style, and format is mostly correct. | Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. | |||
| Total Weightage | 100% |
SOLUTION
Health Assessment
| Issue | Description |
| Chief Complaint | Chest pain and breath shortness |
| History of present illness | The patient who is a 58-year-old woman comes to the health center with a chief complaint of chest pain and breath shortness. According to the patient, she started to experience pain about one week ago. The pain tends to increase with exertion and not when she is resting. The patient further added that the pain is concentrated at the centre of her chest, and it does not radiate to other parts, but it gets worse when exposed to cold. The pain lasts for a few minutes, and when she takes a break or rest, the pain reduces. According to the information provided by the patient, she has also been experiencing fever and nausea. To manage the pain, the patient has been taking aspirin. |
| Past medical history | The patient had been admitted for hypertension a month ago. |
| Past surgical history | None |
| Family history | The grandfather died of a heart disease twenty years ago. Two years ago the father was diagnosed with heart failure. |
| Social history | The patient smokes one pack of cigarettes in two days. She is also an alcohol addict. |
| Allergies | None |
| Medications | Aspirin, vitamins, and Thiazide diuretics for hypertension. |
| Review of symptoms by system | -Fever |
| Physical exam | Cardiovascular examination
-Palpation of the chest -Inspection of the chest Extremities -Examination of pitting edema Examination of the chest -Auscultation of the lungs
|
| Assessment | Tests
Electrocardiogram Chest X-ray Blood tests (Tashakkor, Stone, & Mancini, 2016). From the results of the tests the patient was likely to be diagnosed with angina |
| Treatment plan | The treatment plan for this patient will include:
*Educating the patient on the importance of changing her lifestyle. The patient should stop drinking alcohol and smoking (Moattari, Adib, Kojuri, & Tabatabaee, 2014). *The patient should also be educated on the importance of exercising and how it can help improve her health outcome (Qintar et al., 2016). Medications *The patient will need to take medications. The medications that the patient should be prescribed include: Nitrates: These medications are normally used to treat angina whereby they help in widening and relaxing the blood vessels (Ben‐Yehuda et al., 2016). Beta blockers: These medications help in reducing blood pressure. -The patient should continue taking aspirin because it helps in reducing the ability of the blood to clot making it easier blood to flow easily through heart arteries that have narrowed (Ohman, 2016).
|
References
Ben‐Yehuda, O., Kazi, D. S., Bonafede, M., Wade, S. W., Machacz, S. F., Stephens, L. A., … & Hernandez, J. B. (2016). Angina and associated healthcare costs following percutaneous coronary intervention: a real‐world analysis from a multi‐payer database. Catheterization and Cardiovascular Interventions, 88(7), 1017-1024.
Moattari, M., Adib, F., Kojuri, J., & Tabatabaee, S. H. R. (2014). Angina self-management plan and quality of life, anxiety and depression in post coronary angioplasty patients. Iranian Red Crescent Medical Journal, 16(11).
Ohman, E. M. (2016). Chronic stable angina. New England Journal of Medicine, 374(12), 1167-1176.
Qintar, M., Spertus, J. A., Gosch, K. L., Beltrame, J., Kureshi, F., Shafiq, A., … & Arnold, S. V. (2016). Effect of angina under-recognition on treatment in outpatients with stable ischaemic heart disease. European Heart Journal–Quality of Care and Clinical Outcomes, 2(3), 208-214.
Tashakkor, A. Y., Stone, J., & Mancini, G. J. (2016). Is It Time to Update How Suspected Angina Is Evaluated prior to the Use of Specialized Tests? Implications Based on a Systematic Review. Cardiology, 133(3), 181-190.
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