HEALTH ASSESSMENT PROJECT

NAME: ONIPHA TAPPIN DATE: 31ST OCTOBER, 2012 TEACHER: IS FRANCIS SUBJECT: HEALTH ASSESSMENT

INTRODUCTION

TABLE OF CONTENTS

INTRODUCTION. BIOGRAPHICAL DATA... CHIEFT COMPLAINT... HISTORY OF CURRENT OLLNESS PAST HEALTH HISTORY CURRENT HEALTH STATUS FAMILY HISTORY PSYCHOSOCIAL HISTORY.. NEUROLOGICAL.. RESPIRATORY. CARDIOVASCULAR.. GASTROINTESTINAL.. GENITOURINARY.. MUSCULOSKELETAL.. HEAD TO TOE ASSESSMENT. MEDICAL DIAGNOSIS/ORDER..... NEEDS/PROBLEMS OF THE CLIENT CARE PLAN

BIOLOGICAL DATA

Name: Adrean N Jones Sex: Female D.O.B: 10/09/87 Age: 25 Address: Golden Grove New Extension Tel: 560-3695 Cell: 724-9198

Country of Birth: Guyana Nationality: Guyanese Religion: Moravian Race: Black Marital Status: Engaged Place of Employment: Cedar Hall Moravian Pre-School Occupation: Teacher Tel: 464- 5577

Medical Insurance: Sagicor Next of Kin: Cadeem Browne Relationship: Fiance Tel: 770-4514

CHIEF COMPLAINT

I came in because I have a bump on my eyelid, it is swollen and painful.

HISTORY OF PRESENT ILLNESS

The swelling first appeared on the right upper eyelid two weeks ago. The bump was noticed the following morning one on the eyelid it began quite small and has proceeded to grow to its current size of 0.5cm. The area appeared red and was tender to the touch. The patient has experienced pain on entering areas of bright lighting, excessive tearing and drooping of the eyelid. Cold compresses were applied to aid in lowering the swelling, this failed to improve the condition. This has never occurred before. It hinders focusing on the lesson plans and general comfort.

PAST HEALTH HISTORY

Childhood Illness: No childhood illnesses

Accidents/Injuries: I. Broken arm from fall at age 7 treated and released at Georgetown Hospital. II. Ingestion of foreign object at age 7 hospitalized at Holberton Hospital. III. III. Dislocated thumb at age 12 treated and released at Holberton Hospital.

Chronic Illnesses: None

Obstetric History: Gravida 0/ Para 0/ Abortion 0

Immunization: Up to date

 Hospitalizations: Age 7 to monitor progress of ingested object

Last Examinations: Secondary school physical in 1st form. Last dental exam at age 13. Eye exam for glasses at age 15.

Allergies: None

Current medications: Birth control pills Microgynon, 1/day, for 6 months

FAMILY HISTORY
Adrean is the 1st child and eldest child, parents married, father had similar eye problems in the past. Grandfather died at age 81 from hypertension. Aunt has seizure disorder. High blood pressure present in grandmother, uncle and aunt.

PSYCHOSOCIAL HISTORY
Self-concept Completed all stages of education from primary to college to teachers training. Works at the cedar Hall Moravian Pre-School, a fun and fulfilling job. Lives with fianc. believes in god but does not attend church. Believes self to be loving, kind, and dependable.

Lifestyle Does not smoke but drinks for special occasions once a year. Rarely eats breakfast but believes nutritional status is adequate. Gets approximately 6 hours of sleep. Spends most of the day at work and after reading novels. Does not believe she requires exercise but does maintain an active lifestyle.

Social Describes life as happy but stressful at times. Has a good relationship with spouse and family.

REVIEW OF SYSTEMS
Questions asked in accordance to findings?
What were you doing when the problem occurred? When did the problem first occur and for how long? The place in which it occurred? Did you seek medical attention? If so what was the treatment done and for how long? Has the problem reoccurred since?

NEUROLOGICAL

Question:
Have u experienced any of the following fainting; seizures; loss of consciousness; head injuries; changes in cognition or memory; hallucinations; disorientation; speech problems; sensory disorientation such as numbness, tingling or loss of sensations; motor problems; problems with gait balance or coordination; and the impact on ADLs.

RESPIRATORY
Question:
Have u experienced any of the following- Breathing problems; cough; sputum (colour and amount); bloody sputum; shortness of breath (SOB) with activity; noisy respirations such as wheezing; pneumonia; bronchitis; tuberculosis (TB); last chest x-ray and results; history of smoking.

CARDIOVASCULAR

Questions:
Have you ever experienced any of the following -Chest pain; palpitations; murmurs; skipped beats; hypertension (HTN); awakening at night with SOB; dizzy spells; cold or numb hands and feet; colour changes in hands and feet; pain in legs while walking; swelling of extremities; hair loss on legs; sores that do not heal; results of electrocardiogram, if ever done.

GASTROINTESTINAL
Question:
Have u experienced any of the following -Loss of appetite; indigestion; heartburn; gastroesophageal reflux disease (GERD); nausea; vomiting; vomiting blood; liver or gallbladder disease; jaundice; abdominal swelling; regular bowel patterns; changes in bowel patterns; colour of stool; diarrhea; constipation; hemorrhoids; weight changes; use of laxatives and antacids; date and results of last fecal occult blood test, if ever done.

GENITOURINARY

Question:
Have you experienced any of the following- Pain on urination; burning; frequency; urgency; dribbling; incontinence; hesitancy; changes in urine stream, colour of urine; history of urinary tract infections, kidney infections, kidney disease, kidney stones, frequent night time urination.

MUSCULOSKELETAL

Question:
Have u experienced any of the following- Fractures, sprains, muscle cramps, pain, weakness, joint swelling, redness, limited range of motion, joint deformity, noise with movement, spinal deformities, low back pain, loss of height, osteoporosis, degenerative joint disease, or rheumatoid arthritis; impact on ability to do ADLs; use of calcium supplements.

CURRENT HEALTH STATUS

Reports usual health OK. No recent weight change, no weakness fatigue, fever or sweats. Able to perform activities of daily living without difficulty.

HEAD-TO-TOE ASSESSMENT

Height: 163cm (54) B/P: 100/60 Pulse: 76 bpm

Weight: 59 kg (130lbs) Temp: 97 F Resp: 18 bpm

General survey
Adrean Jones is a 25 year old black female, she articulates clearly, ambulates without difficulty, and is in distress. Cyst present on right upper eyelid.

Skin
Uniform in colour, warm, dry, intact, turgor good. Cyst approximately 0.5cm present over Rt upper eyelid, surrounding area is red and swollen. Hair, normal

distribution and texture, no pest inhabitants. Nails, no clubbing, biting present, no discolorations. Nail beds pink and firm with prompt capillary refill.

Head
Normocephalic, no lesions, lumps, scaling, parasites, or tenderness. Face, symmetric, no weakness, no involuntary movements.

Eyes
Glasses worn. Acuity by Snellen chart 20/30. Visual fields full by confrontation. Extra-ocular movements intact, no nystagmus. Ptosis present in Rt eyelid, excessive tearing noted, no crusting. Sensitivity to light noted. Adequate pupillary reactions. Pain noted on palpation of lesion and surrounding area. Lesion is slightly hardened.

Ears
Pinna no mass, lesions, scaling, discharge or tenderness to palpation. Canals clear. Whispered words heard bilaterally.

Nose
No deformities or tenderness on palpation. Nares patent. Mucosa pink, no lesions. Septum midline, no perforation. No sinus tenderness.

Mouth
Mucous and gums pink, no lesions or bleeding. Slight yellowing to teeth noted. Tongue symmetric, protrudes midline, no tremor. Uvula rises midline. Gag reflex present.

Neck

Neck supple with full ROM. Symmetric, no masses, tenderness. Trachea midline. Thyroid nonpalpable, not tender.

Spine and Back

Normal alignment of spine, no deformities notes. No tenderness on palpation.

Thorax and Lungs

Equal bilateral chest expansion. Breath sounds audible. Lungs field clear with no adventicious sounds. Diaphragmatic excursion equal bilaterally.

Breasts
Symmetric; no retardation, discharge, or lesions. No masses or tenderness on palpation.

Heart
Heart sounds normal no murmurs or thrills present.

Abdomen
Flat, symmetric. Skin smooth with no lesions, scars or striae. Bowel sounds present, no bruits. Abdomen soft no masses or tenderness.

Musculoskeletal
Colour distribution on extremities equal, no deformities or lesions.no tenderness. All peripheral pulses present and equal bilaterally. Full ROM present. No tenderness or weakness in joints. Muscle strength able to maintain flexion against resistance and without tenderness.

Neurologic
Alert and oriented to person, place and time. Thought coherent. Remote and recent memories intact. Cranial nerves ii through xii intact. Sensory; pin prick light touch intact. Able to identify objects.. no atrophy, weakness or tremors. No gait abnormalities, able to tandem walk. Cerebellar, finger-to-nose smoothly intact.

MEDICAL DIAGNOSIS/ORDER

Based on the symptoms a diagnosis of a Chalazion was given. But due to the size being so small no surgery is required. To treat this condition a topical antibiotic eye drop is prescribed Chloramphenicol. The patient is also advised to apply warm compresses for 10-15 four times per day. If cyst continues to go after a month return.

NEEDS OF THE CLIENT

Rest and comfort Knowledge deficit

CARE PLAN
Assessment Swollen, red, painful, upper eyelid with cyst and photophobia Nursing Diagnosis Altered comfort related to inflammatory process evidenced by client verbalizing pain. Goal Client will verbalize a reduction in pain Interventions -Ask the client what aggravating factors cause the discomfort e.g. bright lights. This is so you know exactly what is causing the client discomfort -Advise the client to apply cool compresses for 10-15 mins four times daily. This is to aid in reducing the swelling and clearing the blocked oil gland. -Encourage the client to wear sunglasses in brightly lit places, this decreases discomfort from light sensitivity. -Administer prescribed antibiotics Outcome criteria Client will be free of pain while receiving treatment or verbalize a reduction in pain.

prophylactically as this aids in the quick resolution of the condition thus to relieve discomfort. -Advise the client on the need to monitor for and changes in the condition, as this denotes a resolution or progression of the condition.

Knowledge deficit related to condition evidenced by client verbalizing incorrect beliefs.

Client will have adequate knowledge related to condition evidenced by clients verbalizing correct information

-Have the client state their beliefs and views on the condition and its cause, this is to note where they need further information and correction. -Provide a quiet environment conducive to sharing of information. This is so that the client feels that the nurse is giving them adequate attention and allows them to freely voice their problems. -explain to the client the cause of the condition the care necessary and preventative methods to avoid

-Client verbalizes correct and accurate information about the condition

reoccurrence. This enables them to better understand the condition and take precautions against it. -provide pamphlets to the client on the condition so that they have a source of vital and correct information. -For further information to the client ask the doctor to converse with the client so they can further understand the condition.