General Survey And Health History Essay Example
Type of paper: Essay
Topic: Nursing, Patient, Assessment, Information, Health, Decline, Blood, Print
What part of the interview and examination can be done prior to his mother's arrival? As you enter the room for the first time, what should you observe as part of the general survey? As you complete her history, what areas are especially important? What are the important developmental considerations for Casey?
Interviews and examinations are necessarily conducted upon the arrival of patients in the ER. This will help fill the patient’s medical record which will later on be used by the attending physician in making the necessary prognosis and recommendations about a patient’s case. Part of the physical assessment are the analysis of the patient’s subjective and objective physical and mental health status. The subjective data are usually accomplished through mere observations. However, subjective data should be properly assessed using scales for greater accuracy and for the purpose of uniformity. Such details forming the subjective data includes the healthcare provider’s personal assessment of the patient upon arrival at the ER. This includes patient’s gait, appearance and any notable physical features. On the other hand, objective data are provided which much greater accuracy because these are information that are measured accurately through equipment and techniques. This include the patient’s vital signs and the review of system requiring auscultation, palpation and percussion. Amongst the information that completes the objective data include the result of physical assessment like blood pressure, PR, RR and temperature. These information can be recorded without Casey’s parent.
However, in this case since Casey is a minor, she would require an adult to help provide some of the data in her patient’s record. There are data which can be completed without the presence of her mom. Amongst these would include family health history and patient’s history of medical illness. During the process of the physical assessment, Casey should be informed about any procedure being done to her and her consent must be secured prior to the assessment . It is important to consider Casey’s level of understanding in this process. It should be established that she understood the terminologies used during the interview and the health assessment. Avoid using jargon to prevent problems relating to miscommunication later on.
Considering that Casey have incurred a compound fracture of the left leg, important details must necessarily be checked. Initially, there is the need to check whether patient’s blood circulation is compromised. This can be verified through observation, inspection and palpation. It is also important to note whether patient have any allergies to any kind of medication because this may trigger adverse reaction if wrongly administered to the patient.
How much, if any, functional decline has occurred while Red was hospitalized and how will this affect his recovery? What are the risks and benefits of Red living with Jon and Judy? What are the risks or benefits of Red living at home after discharge? If services are in place would it be considered a safe discharge? Considering all aspects of aging what are the best and appropriate options for Red at this time?
Functional decline is defined as one’s loss of ability, both physical and cognitive, particularly necessary to function effectively and independently (Resnick 44; D'Amico and Barbarito, Assessing the Older Adult)). In the case of patient “Red Yonder” notable physical functioning has been lost as confirmed by observation and review of system that is manifested by the patient during hospital confinement.
In reference to the earlier recorded health assessment of the patient, it revealed that patient manifests both cognitive and physical functional decline. While his cognitive functioning seemed to be restored after hospital confinement and his initial confusion could perhaps very well be due to trauma or that he was missing his glasses or hearing aid, it is not sufficient to assert that patient has fully recovered from cognitive functioning decline because of his refusal to acknowledge that something is wrong with him physical and he requires help. Nevertheless, it is quite significant based on subjective results that patient has significantly weakened physically suggesting a physical functioning decline which is significant. He requires assistance in holding a cup, going to the restroom and even walking, all implying that the patient is not able to function independently without assistance.
If evaluation of his weakness is to be referred to a cause, it could very well have something to do with patient’s high blood glucose level. Lab test reveals that patient’s fasting glucose level was at 118 mg/dl. This is abnormally high for a fasting glucose level where the normal level is only at 70 -100 mg/dl . As a result, patient is observed with signs of weakness and confusion.
The risk of the patient staying with his son is that he might become too dependent of him that he would not care to try to function independently. However, it can have its benefit because he will be able to have another person look after him especially when he is feeling weak. At this time the option of Red being with his son is highly recommended. It is a safe discharge if only Red is oriented and mentally alert and that someone can look after his best interest while recuperating at home.
D'Amico, Donita and Colleen Barbarito. "Assessing the Older Adult." D'Amico, Donita and Colleen Barbarito. Health & physical assessment in nursing. Upper Saddle River, NJ: Prentice Hall, 2012. 871–909. Print.
D'Amico, Donita and Colleen Barbarito. "General Survey." D'Amico, Donita and Colleen Barbarito. Health & physical assessment in nursing. Upper Saddle River, New Jersey: Prentice Hall, 2012. 104-119. Print.
Resnick, Barbara. Restorative Care Nursing for Older Adults: A Guide for All Care Settings. New York: Springer Publishing Company, 2004. Print.
U.S. National Library of Medicine. Blood sugar test - blood. 5 August 2014. Web. 16 March 2015.
Viljoen, M.J. Nursing Assessment: History-taking and the Physical Examination. Upper Saddle, NJ: Pearson South Africa, 1996. Print.