NSN701 Advanced Health Assessment


To make your assessment valid, you must: Choose a framework to aid your assessment, provide all information about your patients, and identify four priority issues using evidence-based literature.

Part 1

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For example, see’some points you should consider’ to find examples of assessment tools and frameworks that will best suit your patient.

Be able to justify your choice of framework for health assessment.

You must back up your justification with literature.

Select one patient (either an in-patient or upon admission) for whom you will be caring over a single shift.

You should identify the stage at which the patient was admitted when your assessment item was introduced.

You will need to consent before you can conduct a thorough health evaluation.

Present the patient’s assessment data. Be clear and logical in your presentation.

This section could be included under the headings/key areas of your framework.Your assessment data should identify normal ranges for this health area and highlight pertinent findings/observations (use italics to highlight).

You should use relevant literature to support the claims.

Part 2

Identify and explain all of the potential and current problems that may be affecting the patient.

Based on the assessment data collected in Part 1, select the four most critical problems.

Justify and discuss why these are important for the patient using evidence-based information and data.

Send a copy of your health assessment framework with your submission. It will not be included in the word count.

Answer to Question: NSN701 Advanced Health Assessment

An assessment tool that fits the needs and requirements of a patient could include a head to toe/bodysystems assessment.

The Health Assessment Framework allows healthcare professionals to bring together their diverse knowledge into specific clinical situations (Harris-Roxas, Harris, & Harris, 2013.

A thorough assessment is conducted upon admission. The time it is considered necessary depends on the patient’s hemodynamic state and his/her situation.

This assessment covers all body systems. Care professionals can use the findings to assess the patient’s overall state.

Any abnormal findings must be followed-up with a specific focus on the affected area of a patient.

According to McCarthy (2014), physical assessments include gathering objective data through various techniques, such as palpation or inspection, auscultation, and percussion.

Smith is 40 years old and is being admitted after a Transurethral Resection of the Prostate.

Smith is currently being treated by an Urologist. He has a history that includes nocturia, urinary retention and benign prostatic hyperplasia.

Smith was in good physical condition prior to being admitted. He was also married to his long-term girlfriend.

Smith lives in an apartment, with his wife. Both are computer programmers.

Smith has a history of anxiety and depression. This is under control now with regular medication.

He also sees the community health department with his spouse once per week.

Before his transfer observations were taken and they have remained steady throughout recovery.

Vital signs: Glasgow Coma Scale – GCS 14 (E=5,V=4,M=5)

Blood pressure: 135/85 mg

Heart Rate: Regularly 82 bpm

Respiratory rate: 15 bpmOxygen Saturation: 99% on nasal prongs@2lTemperature: 37?c

Pain Score: 4/10Output 35mls per hrCatheter Check:

Connector points-intact, closed

Balloon- inflated with 10mls

Bag placement below the bladder

Urine with small clots and a reddish pink hue

Drainage-free flowing

No leaks from drainage tubing

Medical Orders

Postoperative assessments and observation are done regularly

Monitoring of strict fluidContinuous bladder irrigation

Clear fluid administration (tolerated).

Management of pain

Prescribed Medication

1000mls of sodium chloride over 8 hours

Oral Paracetamol – 1g with a 4 hrs interval. Morphine 5mg prn. Oxycodone 5-10mg with a 4 hrs interval.Enoxaparin 20mg S/C daily

Senna every day with ColoxylIntramuscular Ondansetron: 4mg prn 12 hourly

After Smith has finished his lunch, it is noticed that Smith is becoming restless, grunting, pale, and experiencing tachypnoea.

Vital Signs: Glasgowcoma Scale 15 (E=5,V=4,M=6)

Blood Pressure: 96/60mmHg

Regular Heart Rate: 140 BPM

Respiratory rate: 25bpm

Room air has 95% oxygen saturationTemperature: 37?c

Score for Pain: 8/10

Other: In tubing, there are few blood clots

Bladder irrigation liquid balance

Total fluid administration to irrigation = 2800mls Normal Saline

The catheter bag’s total output is approximately 1200 mls

Fluid balance= 1600 ml surplus, so a positive [A-B=C], determines if there is a fluid deficit or excess

It is crucial that patients consent to any health assessment.

This permits the patient to take part in decisions related to health care.

Morgenstern (2010) stated that informed consent must be obtained prior to any healthcare intervention.

Smith needed a catheter for his medical procedure.

Assessment of Head to Toe/Body Systems

General appearance- Anxiety, hygiene, body positioning, mobility, speech patternAlteration may demonstrate neuronal impairmentSkin, nail, hairAssess rashes, lesionsPalpate skin for temperature

Pressure areas should be checked

Take a look at the scalp.

Redness can be caused by poor positioning.

Bilateral swelling may be a sign of kidney failure

Head, neck

Check eye drainage, pupillary response to light, mouth, denture, facial alignment

Dry mucous membrane shows reduced hydration

Facial asymmetry can be a sign that there are neurological issues

ChestInspect retraction/expansion, work of breathing, jugular distensionPalpate lung expansion

The accessory muscle’s working ability is disclosed.

A accessory muscle is used to indicate obstruction of the airway

Abdomen- Check for distension and asymmetry in the abdomen

Sound the bowel

To relieve pain and discomfort from bladder distention, you can palpate four quadrants

You can check the output of your urine

The frequency of your bowel movements and the amount you eat are important.

Peristalsis and abdominal distension indicate intestinal obstruction

Surgery may result in a decrease in bowel sound

Abnormal bowel findings may indicate an abnormal urinary function. Also, genitourinary assessments are required.

Extremities- Check pressure areas in the legs, arms, and feet for pain.

Palpate pedal and radial pulse. Capillary refill in hands, feet, and hands.

Check the strength of your grip

Dorsiflex, plantarflex and other resistance indicators should be considered

Pressure areas and skin health

After surgery, asymmetry may be caused by unequal handgrips and pulses.

Back area – Check the spine, coccyxes and back

You should check for any abnormalities in the spine, skin integrity, or pressure area. Regular changes are needed in patient’s posture.

Drainage and tubes- Check drainage, function, position

While a catheter is in use it will be noted what colour and how consistent the drainage is.

Mobility- determine gait, need assistance

Pre-position patient before standing. Evaluate risk of falling. If necessary, use mobility assistance.

Workplace policy: Document and report on assessment findings

Safety of patients is improved by timely documentation

Based on Smith’s assessment data, four of the most serious problems identified could be: impairment of urinary elimination, poor renal tissues perfusion, potential for dysuria, and anxiety.

Impaired urinary drainage: Infections of microorganisms into the urinary track can affect the defense mechanism.

The harmful microorganisms found in the urinary system are washed away with urine.

With the presence of microorganisms, bladder irritation can occur. When this happens, bladder contracts the smooth muscle to flush out the pathogens. (Miranda Lourenco Junior Miotto Junior & Napoleao 2013, 2013).

The goal of reducing the risk of impaired urinary excretion would be to identify causative factors, assess retention, and determine Smith’s level of interference and hydration.

Smith’s care plan must be considered as difficulties in urinary excretion may also indicate failure in glomerularfiltration.

Renal tissue perfusion. Smith’s proteinuria, and hematuria should also be noted.

It might also involve checking for an increase in creatinine.

Blood Urea Nitrogen altermentation can affect his psychological state.

Glomerular filtering rate can raise blood pressure and increase rennin.

In order to assess the extent of impaired renal function, care providers should evaluate perfusion and renal function (Rosenbaum (2013)).

Sigmund et.al. (2012) state that calories supply the system’s energy needs while reducing blood urea Nitrogen intake would assist in limiting it.

Stress can make a person more susceptible to illness or cause him to become inactive.

Poor renal tissue perfusion can increase commitments in order to encourage optical consequences.

Good nursing management can include encouraging patients, setting goals and enhancing recovery.

Capillaries, which are an integral part of nephrons and carry oxygenation, are essential.

Pyelonephritis or any other type of renal disease can affect nephron function. However, kidney perfusion continues to decline (Kanno Yamada Sakamoto Higashi and Sakamoto (2013)).

This type of impaired perfusion reduces the production of erythropoietin by the kidneys.

Reducing the number of red blood cells can further reduce the oxygen supply to the kidneys. Lee, Lee, & Cho (2012).

Smith would change his lifestyle to avoid more complications.

Dysuria may be a sign that there is renal dysfunction.

A proper nursing management could ensure that the body has good flow and is hydrated.

Tachycardia or orthostatic hypotension can indicate hypovolemia.

Galbraith, Wilbanks, & Geisler (2014) mentioned that lower urine flow could indicate urinary retention, increasing pressure on the upper ureter.

Proper care can help control pain. Therefore, the recommended rest time should increase to ensure comfort and sleep.

Stabilizing dysuria, which is the main care plan for this patient, is essential as his pain did not respond to regular paracetamol. It is also known from his medical history that he has an allergy to penicillin.

So it’s a challenge for doctors to evaluate his current medications and determine whether any allergic reactions have been identified after his admission to the ward.

Anxiety: Clear communication with patients regarding their health status helps to reduce anxiety and stress.

Smith would feel empowered if he were involved in his own healthcare.

This encourages faster recovery.

Smith was transferred from the emergency room. While he was being transferred, he was alert and oriented.

His blood pressure was very normal with an elevated heart rate.

Smith did not need any oxygen because his oxygen saturation level of 99% was sufficient.

Smith was breathing normally and scored 4/10 while experiencing pain sensation.

Smith’s moderate pain is evident.

Smith’s urine was dark, cloudy and produced 35mL/hr.

He had a lower output than usual (approximately 33.3-83.3 mL/hr.

This indicates that there is an abnormality in the excretion.

Leukocytes indicate infection as these colorless cells (leukocytes), help fight off foreign particles. Smith et al. (2015).

This information is necessary to diagnose Smith.

Since nursing care relies on this initial assessment, Smith’s care providers should create a holistic care plan.

Smith’s nurse chart should have three main areas. They should include pain assessment, catheter checking, and recording intake and fluid output.

Smith should be admitted to the ward and nurses must immediately begin to provide nursing services.

An assessment of pain would help him feel comfortable. Prescriptions would be made (Kress Su & Wang 2016).

This would prevent him from having bladder spasms.

Smith may feel constricted by the attached catheter. The catheter is tapped tightly onto Smith’s leg to prevent bleeding.

The color change in urine (clear/pink/red), determines the degree of catheter release.

Clear urine allows catheter to be released.

Important is keeping track of fluid intake and outflow.

Bladder irrigation is important, as it helps keep urine clear and remove any clots.

This prevents any kind of obstruction from occurring within the catheter.

Bladder irrigation will not stop the production of urine or decrease the bleeding. But, once the urine is clear, the process can be stopped.

Smith’s severe injuries could occur if the documentation of all these clinical procedures is not perfect.

Also, information may be miscommunicated within the care team.

Smith was given Enoxaparin 20mg daily. This decreases blood-clotting capacity and helps to prevent the formation of bloodclots.

Enoxaparin bonds with an antithrombin to create a complex which activates clotting factors: Xa irreversibly.

Because it has a low molecularweight, it does not work as well against thrombin.

It would be helpful to reduce his anxiety by giving him 20 mg of Escitalopram Oxalate.

It is one of the selective serotonin–reuptake inhibitors. It has no effect on dopamine and norepinephrine.

This compound does NOT antagonize H1 receptors of histamine or alpha adrenergic cells.

The intramuscular ondansetron 4mg prn medication order is important as it prevents nausea and vomiting post-operatively.

Smith underwent a transurethral resection to his prostate.

Ondansetron has a good safety record, although side effects like headaches and dizziness are common.

Therefore, nurses must carefully monitor all doses and notify their doctor immediately if there is any concern.

This discussion suggests that nursing knowledge is comprised of four major concepts, which could include client, nurse, and environment.

Major nursing education has a strong focus on systematic health assessment.

This aspect has influenced the dominant nature of nursing theories.

No matter the practice context, nursing still involves the systematic evaluation of clients and their families.

To understand people, a general understanding of human needs can be a key theoretical foundation.

Nursing professionals can make a comprehensive assessment of core human requirements by combining subjective and objective information.

However, personalized nursing care integrates understanding of individuals’ typical needs and goals to help determine if the individual is being fully met.

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Safety and efficacy in ureteroscopy following treatment for obstructive polyphritis. International Journal Of Urology, 20(9), 917-922. https://dx.doi.org/10.1111/iju.12060Kress, D., Su, Y., & Wang, H. (2016).

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