Health Assessment Essay

1643 words - 7 pages

[Type text] [Type text] [Type text]2HEALTH ASSESSMENTThe process of evaluating the health status by inquiring the health history and performing the physical exam is known as health assessment. Pseudo name is used to uphold the confidentiality of the client. In accordance with College Of Nurses Of Ontario (2009) nurses have moral and lawful obligations to look after the secrecy and protecting the client health data acquired while providing care. This paper discusses the results of the demographic and historical, subjective and objective data acquired while performing the assessment.Mrs. K is 89 years old with history of stroke, atherosclerotic heart disease, congenital urinary deformity (CUD) and hypertension (HTN). She is also diagnosed with diabetes, asthma and arthritis. Mrs. K resides at York Extendicare. Her glucose levels are monitored everyday. Due to her medical history resident sometimes experience shortness of breath (SOB), anxiety and restlessness. Mrs. K has a mobility limitation as she is one-person transfer and is in wheelchair. Mrs. K is also at a risk of falls. She requires extensive assistance by a health care aid to complete all aspects of hygiene. Mrs. K can wash her face and hands with some cueing and guidance. She is on diabetic regular diet. She wears prescribed glasses. She also wears dentures. Neurological assessment was performed on Mrs. K. The purpose of a neurological assessment is to detect neurological injury in the patient, monitor its progression to determine the type of care to provide, and gauge the patient's response to the interventions (Noah, 2004). Neurological assessment was done on Mrs. K since she presented left side hemiplegia following the stroke 34 years ago. Stroke results in acute loss of neurological function due to an abnormal perfusion of brain tissue (Jarvis, 2009, p. 696). The initial evaluation covered several critical areas of assessment, including level of consciousness (LOC), orientation, speech, facial symmetry, motor and sensory function. The comprehensive evaluation covered assessment of cranial nerve function, cerebellar function and reflex activity.Health Assessment Interview DataA series of questions were asked from Mrs. K to gather information for the assessment. Mrs. K was dressed appropriately and was sitting in wheelchair. She appeared alert and was listening intently to all the questions. When inquired about headaches resident stated she had no unusual frequent or severe headaches. She had a head injury in a car accident 50 years ago. She could not recall the exact date. She has not experienced any loss of consciousness due to head injury. Mrs. K has not encountered dizziness or vertigo and seizures. Following the stroke Mrs. K started having tremors in the upper and lower extremities particularly on left side. She has weakness in her life side since she is hemiplegic. She is in wheelchair therefore she has problems with coordination and requires assistance with activities of daily...

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