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  • Subject Name : Nursing

Nursing Assessment

The 36-year-old patient admitted to the hospital with the major complains of increased urination with dizziness that leads to falling. She explained that she is facing an issue while completing her daily routine due to her deteriorated health and foot wound which is hampering her job. The patient explained that she is feeling fatigued and foot wound is increasing his complication. The personal information reveals that the patient weighs 195 lbs with a BMI of 29.5 kg/m2 and she is working in an MNC from past 5 years. The patient has a habit of smoking, drinking on alternate days with 7-hour sleep of daily bases; she is using a pre-cooked meal for lunch and dinner.

The patient medical history reveals the presence of hypertension and dyslipidaemia that she has experienced one year ago. She was facing issue from the past 4 days due to the foot wound because of the pain and increase walking difficulty. The family history of the patient reveals the presence of diabetes to her father and her mother was a patient of hypertension with a cardiac attack. She is now living with her one son after her divorce and she has experienced a depressive episode after her divorce that she handled after attending the cognitive behavioural therapy. She belongs to a middle-class family that helps her to spend a good lifestyle in a remote area with all the facilities nearby and she can sustain her son's lifestyle.

During the administration, patient vitals reveal that RR 20 breath/min, SpO2 99%, HR 90 bpm, BP 145/99 mmHg and T 38 Celsius. The general inspection report reveals that gait is uncomfortable, body build is normal, conscious and facial expressions are anxious. The medication routine that has been followed by the client includes Benazepril, Orlistat and Ezetimibe. The patient is following the dose and routine of the medication as prescribed by the doctor to decrease deterioration of the health status.

Head to Toe Assessment

Physical Assessment:

Nursing assessment is important to identify the issue with the patient health status that is important to diagnosis the disorder to start the treatment. The health to toe assessment is important to identify all the different aspect of the patient that is important to identify the health-related issue. The head-toe assessment helps to identify the physical, emotional and mental aspect to identify the issue that is altering the wellbeing (Toney-Butler & Unison-Pace, 2020).

The first parts of the assessment include skull assessment which includes observation of the size, shape and contour of the skull. The skull assessment is important to identify the presence of any injury that can lead to health-related complication. The assessment is performed by palpitation. Scalp and hair assessment is also included skull assessment as they also indicate the presence of any issue (Ibáñez et al., 2016). The patient skill was normal and round with no tenderness during the palpitation. The hair consistency was normal overall the scalp and they are bite dry that is normal corresponding to the assessment. The scalp was lighter in colour with no lesion or sing of injury that indicates the normal condition of the scalp.

The next parts of the assessment examine the faces which help to identify the facial features and presence of any sign that can indicate the presence of trauma that can deteriorate the health status of the patient (Truong, 2017). The face shape of the patient is normal that is observed after the assessment. There is no facial drop that is observed in the patient and face colour was also normal. The face symmetry is also observed by smiling of the patient and it was also normal there is no issue concerning the faces symmetry of the patient.

The cranial nerve assessment is the next part of the assessment that is important for the neurological assessment of the patient. There are 12 cranial nerves but out of them V is trigeminal that has both sensory as well motor functioning related to the face (Damodaran et al., 2013). The patient sensory functioning of the patient is normal as the patient is normal closing or blinking the eyes and she is also able to sense the touch to the face. The motor response of the also perfect she was able to chew and bite. Another cranial nerve that is important to judge the motor and sensory function includes VII that I facial nerve and assessment of its four nuclei is important (Damodaran et al., 2013). The patient has normal motor and sensory functioning with the right understanding to taste, movement of the facial muscle.

The neck assessment is the next to identify any misbalance in the muscle or the movement that can be a sign of any issue. The assessment is important to evaluate the neck muscle, lymph node, trachea, carotid arteries with jugular vein and thyroid gland. The assessment is performed by inspection, palpation and auscultation to analyse the current state of the patient (Linkov et al., 2016). After the next assessment, it was revealed that the patient does not have any issue concerning the neck movement or the neck muscles that are increasing complication for the patient. 

Skin assessment is included in the head to toe assessment as skin is the reflection of the individual health that is important for the assessment. Skin is important to identify the presence of any lesions or rashes that can indicate the presence of any issue (Baines et al., 2017). The skin colour is considered to be a little darker due to the hypertensive state of the patient and the wound in the foot need urgent attention as the wound healing has been delayed. The temperature of the patient is also raised that is identified after the assessment.

Respiratory assessment is perfumed in the head-to-toe assessment to evaluate the lung functioning status which will help to identify any breathing issue faced by the patient due to any misbalance in the body functioning. The respiratory assessment includes analysing the respiratory rate, depth of respiration, the pattern of respiration and presence of any sound during respiration line wheezing (Johnson & Smith, 2016). The respiratory rate of the patient observed after the assessment is 23 breaths per minute that are considered to be Tachypnea state. The oxygen saturation is also low that is approximately 90% that need to be addressed urgently.

Cardiac assessment in head to toe aims to understand the status of cardiac functioning that is important to identify the issue in the cardiac functioning. The cardiac assessment is performed to identify the cardiac output, capillary refill time, blood pressure and heart rate. These factor assessment help to identify the issue that is directly affecting the healthy heart functioning (Fritz & McKenzie, 2015). The current heart rate of the patient is 120 beat per minute that comes under the increased heart rate and the patient also has elevated blood pressure that is increasing patient complication.

Abdomen assessment also important to in the health to toe assessment to identify any issue with the different organs that are present in the abdominal cavity which can lead to increased complication of the patient. The abdominal assessment starts with subjective data collection that includes information about the diet, weight loss or gain and food allergies. Some other aspects that are included in the assessment include bowel movement information, GIT tract medical history pain and any bulging (Reuben, 2016). The abdominal assessment reveals no issue with the patient health status and she is using a pre-cooked meal that can lead to complication for the patient.

The genitourinary assessment should also be performed during the head to toe assessment to identify the issue associated with the urinary tract. The genitourinary assessment is important to collect information concerning the urine output, odour, pain or blood during urination and presence of any infection (Nogueira & Paz, 2016). The patient assessment findings reveal that there is an increase in urine output with no pain or burning sensation. The data does not reveal any clue about the presence of infection or blood in the urine.

Endocrine assessment is important to identify the physical changes corresponding to the level of the hormone which can increase complication for the system. In human body endocrine system play a major role in maintaining different functionality thus there is need to analyse the different aspect of the glands and body signs that indicate the presence of any issue (Beronius & Vandenberg, 2015). No abnormity is observed in the physical assessment of the endocrine glands and the signs are also present that indicate the presence of any abnormality.

Diagnostic Test

Blood analysis test is performed to analyse the physical and chemical composition of the blood to identify the deviation from the normal reading that will indicate the presence of the disorder. The blood test is important to identify the efficacy of the different organ functioning like kidney, liver, pancreases and thyroid. It is considered to be one of the markers for the diagnosis of the disease that is associated with the patient symptoms which can help in the treatment process. Different blood tests are performed under the blood analysis which includes complete blood count, blood chemistry test, blood enzyme test and disease diagnosis test (Czarkowska-Paczek et al., 2018). The patient blood analysis test reveals that her blood glucose level is 200 mg/dL that indicate the diabetic state of the patient. The cholesterol level of the patient is also high that is about 239 mg/dL that indicate the Hyperlipidemia is reencountered by the patient that is increasing complication.

Urine analysis is conducted to identify the abnormality in the body functioning unit that can be detected by the concentration of the different component in the urine. It is important for the diagnosis of the disorder, identifying the kidney function and monitoring patient current health status. Different tests are conducted in the urine analysis that includes a physical examination, biochemical examination and microscopic test to identify the issue. It is considered to be the initial examination for identification of the issue that can be followed by the specific test for the disorder (Delanghe & Speeckaert, 2014). The urine analysis reveals that the patient is facing polyuria condition that is urine output greater than 3000ml/day and the urine is colourless that occur during the diabetic condition. The patient urine is very concentrated that lead to the condition of hypersthenuria that also indicate the presence of diabetes mellitus. Biochemical examination reveals the presence of the condition glucosuria that indicate the secretion of the glucose in the urine.

Differential Diagnosis:

The ketosis is one of the differential diagnosis tests that can be used to differentiate between type1 and type diabetes. Ketosis indicates the presence of the ketone in the urine that indicates the presence of type 1 diabetes with a complication of diabetes ketoacidosis which can deteriorate the health of the patient. The ketosis is also important to continuously track the level of ketone in the urine to reframe the diet to decrease the chances of the complication (Urbain & Bertz, 2016).

The increase in blood pressure and racing heart rate can also indicate the presence of the heart issue as the patient family history also reveal cardiac failure. Echocardiography will be conducted to identify the waves generated from the heart. The ultrasound waves are utilized to image the different heart chamber that is important to diagnosis the cardiac issue. The patient with susceptible to heart disorder like symptoms or family history requires to conduct the echocardiography to confirm the presence of issue. Different echocardiographs can be utilized to identify the issue and the type of method is preferred concerning the patient health status (Price et al., 2017).

The CT scan will also be included in the differential diagnosis to identify the presence of any issue concerning the kidney functioning due to the patient increased output. The CT scan is important to identify the proper kidney functioning by identifying the presence of lesion, stone or issue with kidney internal structure. The imaging test is important to correlate the symptoms of the patient with any disorder concerning the kidney functioning. The increased or decreased size of the kidney is also important to diagnosis the presence of deformities that lead to disturbance in the urine output (Brisbane et al., 2016). The increased urine output of the patient is also one of the signs of the misbalance of kidney function. Thus there is a need to conduct the CT scan to identify the current state of the kidney functioning

Another differential test for the type 1 diabetes is Glutamic Acid Decarboxylase Autoantibodies test that is specialised designed for the type 1 diabetes. It is considered to be the peptide test that measures the amount of insulin in the body specifically for type 1 diabetes. The test is measured on the measurement of the identification of the particular type of antibodies that are involved to destroy the own GAD cells. In type, 1diabetes autoantibodies are developed that are circulating and involved in to target the glutamic acid decarboxylase. This is considered to be the confirmatory test for the type 1 diabetes that is identified by the presence of autoantibodies (Tohid, 2016).

Treatment Plan:

The nursing care plan is important to provide accurate suggest the accurate intervention for the patient concerning the health status of the patient. Different points are to be considered in the care plan which issue priority issue, outcome, nursing intervention and evaluation process. These points are included to develop the treatment that is important for the patient to improve the health status by addressing the issue with the patient.

Issue: Some of the issues that can increase complication for the patient includes

  • The increased blood glucose level
  • Hypertensive state
  • Decreased oxygen saturation
  • Foot wound

Outcome: The outcome that is expected from the intervention includes

  • Decrease blood glucose level and better maintenance of the fluctuation in the level
  • Decrease blood pressure
  • Improved oxygen saturation level and better breathing
  • Better healing and no chances of infection

Intervention: Some of the intervention that can be utilized for addressing these issues includes

  • The insulin is considered to be the first-line treatment for the diabetic patient as it helps to decrease the blood glucose level which is not occurring naturally due to misbalance of the insulin concentration. Insulin is the medication is important for the diabetic patient to take before their meal to decrease the chances of the greater increase of the blood glucose level which can cause the issue. There are different type of insulin that is utilized to support the patient blood glucose level (Vecchio et al., 2018).

The self-management training can also be provided to the patient to improve their understanding concerning the different technologies that can be utilized after the discharge to improve blood glucose level. The self-management intervention is important to teach patient about blood glucose monitoring, managing diet and maintain the fluctuation in blood glucose level (Shrivastava et al., 2013).

  • The propranolol is utilized to address the hypertensive state of the patient by decrease the blood pressure. It belongs to the class of beta-blockers that are involved to block the work of the hormone epinephrine that are involved to increase the heart rate. Propranolol is considered to selectively block the Beta 1 receptors in the heart that will directly decrease the contraction force of the cardiac output. The result of the blocking lead to a decrease in blood pressure by the process of the vasodilation (Steenen et al., 2016).

Lifestyle intervention is also recommended to address the increased blood pressure by the non-pharmacological method. The lifestyle intervention includes dietary and physical activity session to improve patient understanding. The dietary intervention will improve the calories intake that is important to decrease the blood pressure. The physical activity is also important to improve the energy expenditure and intake which is important for maintaining the blood glucose level (Lv et al., 2017).

  • Oxygen therapy is utilized to address the decrease in oxygen therapy which is necessary to improve the health status of the patient. Oxygen therapy is the administration of the oxygen concerning the concentration of the pressure greater than the environmental atmosphere concentration. There are three advantages of oxygen therapy which includes treating hypoxia, decreased work of breathing and decrease myocardial work. Different modes of oxygen therapy should be used for the therapy but the preferences of the method should be patient condition and choice (Cousins et al., 2016).
  • The wound management is important to address the wound of the patient that is required to improve the healing and decrease the infection. The health care professionals are considered to provide accurate care to the patient with the wound to decrease the healing time. There are five principles of the wound management include haemostasis, cleaning the wound, analgesia, skin closure and dressing (Tricco et al., 2015).

Evaluation: The evaluation will be conducted my patient assessment to identify the impact of the intervention over the patient and patient self-reporting will also be considered to understand the patient perspective. These interventions will help to improve the health status of the patient by addressing the pain issue that is addressed after the patient assessment. The interventions are framed as per the patient-centric approach to improve the patient health status and decrease the recovery time.

The therapeutic communication will be utilized to assist the patient and the family concerning the patient current health status and treatment that has been utilized to decrease the complication of the patient. The referrals will be provided to the patient so that she can get the assistance if she encounters any complication concerning the health status. The follow-up plan will be framed with the patient so that short term checking of the patient can be done to understand the impact of the patient. The patient will also be educated about the non-pharmacological intervention so that it can be included in the daily routine to improve and sustain the health status. 

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