HEALTH ASSESSMENT

Name: Onipha Tappin Date: 31/10/12 Teacher: Sis Francis Subject: Health Assessment

Introduction
In this project you will find all the information required in the care of the client in order to give proper care and treatment. I hope you find it informative and helpful.

Health Assessment: a plan of care that identifies the specific needs of the client and
how those needs will be addressed by the health care team.

Chalazion: a small bump in the eyelid caused by a blockage of a tiny oil gland.

Table of Contents
Introduction.1 Biographical Data2 Chief Complaint3 History of Current Illness...3 Past Health History..3-4 Current Health Status..4 Family History..4 Psychosocial History...5 Neurological Assessment.6 Respiratory Assessment...6 Cardiovascular Assessment...6 Gastrointestinal Assessment.6 Genitourinary Assessment.6 Musculoskeletal Assessment6
Skin, head/neck, eye, ears, nose, mouth/ throat, breast.7

Head-to-Toe Assessment8-10 Medical Diagnosis/Order11 Needs/Problems of the Client.11 Care Plan12-15

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

Country of Birth: Guyana Nationality: Guyanese Religion: Moravian Race: Black Place of Employment: Cedar Hall Moravian Pre-School Occupation: Teacher Marital Status: Engaged Next of Kin: Cadeem Browne Relationship: Fianc Tel: 770-4514 Tel: 464-5577

Address: Golden Grove New Extension Medical Insurance: yes Family physician: Dr Moulon The source of information is reliable Informant: Adrean Jones Company: Sagicor

Subjective Data
Chief Complaint
Bump on eyelid for 14/52, it is swollen and painful.

History of current illness

Last well until two weeks ago, on waking client observed swelling of right upper eyelid. The following morning on examination the client felt a large bump, painful to touch. Cold compresses were applied with no improvement. It is accompanied with photophobia, excessive tearing, eye pain and heaviness of the lid. Last eye examination 6 years ago. First episode of condition. Client wears glasses daily for near sightedness treatment. No history of blurred vision, eye injury, double vision, cataracts or glaucoma, eye surgery, retinal detachment, strabismus, or amblyopia, loss of vision or parts of fields. Client unable to read for long periods of time due to fatigue of the affected eye.

Past Health History

Childhood Illnesses: No history of mumps, mumps, chickenpox, rubella, frequent ear infections, frequent streptococcal infections or sore throats, rheumatic fever, scarlet fever, pertussis, or asthma. Accidents/Injuries: Broken arm from fall at age 7, treated and released from Georgetown Hospital. Ingestion of foreign object (marble) at age 7, admitted to Holbderton Hospital x14/52, treated and released. Dislocated thumb at age 12 treated and released from Holberton Hospital.

Obstetric History: Nulliparous

 Immunization: All childhood vaccinations received measles, mumps, rubella, chickenpox, hepatitis B, diphtheria, polio. Tetanus 2nd booster to be received. Hospitalizations: At age 7 for 14 days to monitor progress of ingested object. Last Examination: Secondary school physical in 1st form. Last dental exam at age 15years. Eye exam for glasses at age 16years.

Allergies: No known allergies. Current Medications: Birth control pills Microgynon 1/day since April 24th, 2012.

Current health status

General health is OK. No changes in appetite or weight. Able to perform ADLs without difficulty. No history of weakness, unexplained fevers, or unusual symptoms.

Family History
Father has had similar eye problems in the past. Maternal grandfather died at age 81 years due to complications of hypertension. Maternal aunt has seizure disorder. High blood present in maternal grandmother, maternal uncle and maternal aunt. No history of heart disease, cancer, diabetes, tuberculosis, stroke, bleeding disorders.

Psychological History
Self-concept
Completed all stages of education from primary to college to teachers training. Works at the Cedar Hall Moravian Pre-School as a teacher, describes it as a fun and fulfilling job. Believes in God but does not attend church. Believes self to be loving, kind and dependable.

Lifestyle
No smoking, drinks on special occasions such as carnival and Christmas, one to two beers. Diet- Does not eat breakfast, and sometimes skips meals. Believes nutritional status is adequate but could be better, such as eating 3 square meals, and a more balanced diet. Exercise- Does not have a set exercise program but takes regular walks with fianc. Psychosocial- Has a good relationship with friends, family, partner and coworkers. Lives in a two bedroom one bath home with partner and 5 dogs. Describes life as happy but stressful sometimes due to long work hours. This she copes with by finding a quiet place to read a good book and relax and talking problems over with partner or sisters. Economic- Believes economic status is adequate but could be better in ways of savings.

Review of Systems

Neurological: No history of 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. No impact on ADLs.

Respiratory: No history of breathing problems, cough, bloody sputum, SOB

with activity, wheezing, pneumonia, bronchitis or tuberculosis. Last chest x-ray was 18 years ago to note progresses of ingested object, no abnormalities noted.

Cardiovascular: No history of chest pain, palpitations, murmurs, skipped

beats, hypertension, awakening at night with SOB, dizzy spells, cold hand or feet, colour changes in hands and feet, pain in the legs while walking, swelling of the extremities, hair loss on legs, poor wound healing. Has never done an EKG.

Gastrointestinal: No history of loss of appetite, indigestion, heartburn,

nausea, vomiting, liver or gallbladder disease, jaundices, changes in bowel patterns; colour of stool, constipation or diarrhoea, hemorroids, weight changes (loss or gain), use of laxatives and acids.

Genitourinary: No history of pain on urination, burning, urgency, dribbling,

incontinence, hesitancy, changes in urine stream or colour, no history of urinary tract infections, kidney infections, kidney disease, kidney stones, or frequent urination at night.

Musculoskeletal: History of fractures. No history of sprains, muscle cramps,

pain, weakness, noise with movement, spinal deformities, low back pain, loss of height, osteoporosis, degenerative joint disease, or rheumatoid arthritis.

 Skin: No history of rashes, lumps, sores, mild dryness, no colour changes. No history of changes in hair or nail. Head/Neck No history of unusual headaches, head injury or surgery, dizziness, loss of consciousness or fainting. No history of stiff neck, injury or surgery, pain with movement of head and neck, swollen glands, nodes or masses. Eye: See history of present illness. Ears: No history of difficulty hearing, sensitivity to sounds, ear pain, drainage, vertigo, ear infections, ringing, fullness in the ears. Nose: No history of nosebleeds, use of recreational drugs, allergies, broken nose, difficulty breathing through the nose, sneezing. Mouth/Throat: No history of sore throats, streptococcal infections, mouth sores, oral herpes, difficulty chewing or swallowing, changes in sense of taste. Breast: No history of masses pr lumps, discharge, pain, swelling, changes in breast or nipple, breast cancer, breast surgery.

Head-to-Toe Assessment
Height: 163cm (54) B/P: 100/60mmHg Pulse: 76 bpm Weight: 59kg (130lbs) Temp: 97F Resp: 18 bpm

General health survey: Adrean Jones is a 25 year old black female, she articulates clearly, ambulates without difficulty. Skin, Hair, Nails: skin, uniform in colour, warm, dry, intact, turgor good. Hair, normal distribution and texture, no lice or other 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. Drooping present in right eyelid, excessive tearing noted. Photophobia noted. Adequate pupillary reactions bilaterally. Lesion approximately 0.5cm present over RT upper eyelid, lesion and surrounding area is red and swollen, painful to touch, not mobile. Acuity by Snellen chart 20/30. Visual fields adequate by confrontation. Extra-ocular movements intact, no nystagmus. Ears: Symmetrical with no deformities. Canals clear. Pinna, no mass, lesions, scaling, discharge, or tenderness on palpation. Whispered words equally heard.

 Nose: Symmetrical. No deformities or tenderness on palpation. Nares patent. Mucosa pink, no lesions. Septum midline, no perforation. No sinus tenderness. Mouth: Mucosa and gums pink, no lesions or bleeding. Slight yellowing to teeth noted, no cavities present. Tongue symmetric, protrudes midline. Uvula rises midline. Gag reflex present. Neck: Symmetric, no masses, tenderness. Trachea midline. Thyroid nonpalpable, not tender. Neck supple with full ROM. Spine and Back: Normal alignment of spine, no deformities noted. No tenderness on palpation. Thorax and Lungs: Equal bilateral chest expansion. Breath sounds audible. Diaphragmatic excursion equal bilaterally. Lungs field clear with no adventitious sounds. Breasts: Symmetric, no discharge or lesions. No masses or tenderness on palpation. Heart: No pulsations, lifts or heaves. 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 organomegaly. 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 made. 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 minutes four times a day. If bump continues to grow after a month return for further analysis.

Needs of the Client

Pain relief knowledge

Care Plan
Assessment Nursing Diagnosis Altered comfort (pain) related to inflammatory process evidenced by client verbalizing pain. Goal Interventions Outcome criteria Client will be free of pain while receiving treatment or verbalize a reduction in pain.

Swollen, red, painful, upper eyelid with bump and light sensitivity

Client will verbalize a reduction in pain

-Advise the client to apply warm compresses for 1015 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 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

-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.

-Client verbalizes correct and accurate information about the condition

correct information

-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 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.