|Type of paper:||Research paper|
For the completion of a comprehensive, patient-centered head-to-toe assessment, a number of interviewing skills were appropriate. To start with, communication skills were paramount as they served as a fundamental link between my expertise in the nursing practice and the patient. Although the communication process may appear like a simple task, it requires one to have knowledge about how to communicate with a patient in a way that encourages respect for the nurse while enabling the practitioner to get a complete and accurate health history. Another key interviewing skill is active listening. This involved hearing what the patient was saying while simultaneously processing and interpreting her words to gain a profound understanding of the message being delivered. To achieve this, I ensured that the patent got my full concentration and attention that was free of interruptions and distractions, both internal such as personal judgment and unnecessary matters, and external, for instance, ringing telephones and infringement from other persons.
Empathy was also crucial whereby I put myself in the patient's shoes making her feel that I understood her unique experience and that I was applying my nursing expertise to her as an individual. Additionally, my ability to build a good rapport with the patient helped me to set a suitable interview tone which allowed the patient to feel comfortable with me. Consequently, the patient offered information freely and without contradiction. Other key interviewing skills that were key to the assessment included the use of open-ended questions, avoiding leading questions, maintaining silence during the interaction, maintaining eye contact, appropriate choice of language and use of facial expressions, gestures, and movements.
Data Collection Techniques
For the collection of the assessment findings, various data collection techniques were adopted namely Interview, physical examination (PE) and clinical examination. The interview method of data collection included a conversation with the patient which was very instrumental in the gathering of information that will determine the treatment plan to be adopted. This was used in combination with observation as I had to observe the patient throughout the interview session. During the interview, a review of systems (ROS) was also done which included completing a comprehensive review of systems questioning. Physical examination was also used as a data collection technique whereby it involved the measurement of vital signs such as the patient's weight, height, blood pressure, pulse, RR, HR, BP, Pulse ox, and temperature. Also, clinical examination was adopted for data collection through Inspection and Palpation. While inspection helped me to focus on the patient's nutritional state and speech, palpation enabled me to assess the specific body parts that required further attention.
Appropriateness of the Data Collection Techniques
The data collection techniques adopted for this exercise were the most appropriate for each body system assessed. For instance, through the interview, I was able to obtain the information I required from the patient with regard to their health history. This is in line with the findings of Nirmala (2011) that interviews carried out verbally serve as key sources of information for treatment planning. The interview technique was the most appropriate in relation to gaining insights into the patient's details and the history of her present illness. Through interview also, the medications that the patient was already undergoing were revealed. According to Nirmala (2011) patient interview is critical to understanding the client and the presence or absence of related symptoms to the current illness. Regarding physical examination, it was the most appropriate technique for obtaining data related to the patient's weight, height, blood pressure, pulse and temperature as it allows for the measurement of vital signs. A study by Sherry et al. (2011) found that physical examination is crucial as it enables the development of an individual systematic approach that helps to obtain accurate and thorough findings from patient assessments. In this case, PE helped to obtain key biophysical data by the use of specialized equipment. For instance, the patient's weight was found to be 84 kg, a height of 170 cm, a blood pressure of 128/82, Pulse Ox at 99% and a temperature of 99.0 F.
Additionally, clinical examination was also the most appropriate in terms of objectifying the data that was gathered during the interview. This was in accordance with Williamson's (2017) argument that clinical examination is a key component of the preliminary data and information required for treatment planning. Clinical examination involves four techniques namely inspection, palpation, auscultation and percussion (Williamson, 2017). However, due to the nature of the current patient's condition only inspection and palpation techniques were used. As earlier stated, the inspection was the most appropriate technique for gaining from the patient's visual information such as speech and nutritional state. As stated by Sherry et al. (2011), inspection enables one obtain visual information such as behavior, general appearance, tone and nutritional condition. Further, palpation was the most appropriate in the determination of the patient's organ characteristics such as temperature and texture through a touch. Based on research findings, Williamson (2017) suggests that palpation provides a suitable way of assessing various parameters of a patient's body such as the site of pain, skin texture, humidity of the tissues and body temperature by making use of touch.
Comparison of Findings with Established Norms
When the patient's body systems are compared with established norms for healthy adults, significant differences become evident. To start with, the patient had a height of 1.7m and weighed 84 kg resulting in a Body Mass Index (BMI) of 29.0. According to the established norms, BMI, which is the most widely used approach to measure obesity, for both men and women who are 20 years and over, the following BMI ranges are expected. Underweight persons have a BMI of less than 18.5, the normal range for the healthy falls between 18.5 and 24.9, the overweight persons have a BMI of between 25 and 29.9 while those with a BMI of 30 or over are considered obese (Sherry et al., 2011). From this comparison, it can be deduced that the patient is overweight. The patient's weight is also higher than that recommended by the established norms. The average weight for normal female American is given to fall in the range of 60 to 72 kg (Williamson, 2017) while the patient weighs 84 kg.
Another key factor for comparison is the blood glucose whereby that of the patient is at 100. According to the established norms for healthy adults, for normal persons, blood glucose should be below 100 (Williamson, 2017), a measure of between 100 and 125 indicates prediabetes while a glucose level of 126 or more in the blood suggests one has diabetes. From this information, the patient does not fall under the normal blood glucose levels indicating that she is in the early stages of diabetes. Other measurements of the vital signs for a normal person include a RR of between 12 and 20, a HR of between 60 and 100 beats per minute, a temperature of between 977 and 99.5 and a pulse ox ranging from 60 to 80 percent (Sherry et al., 2011) all which the patient satisfies. However, her blood pressure is higher than that expected for a healthy person, of less than 120/80. The patient has a pulse ox of 128/82.
Health Risks Identified
There are a number indicators that were discovered in relation to the patient's illness. One of the key indicators noted is that the patient has excess weight. This was demonstrated by her weight, 84 kg, which was above the recommended 60-72 kg. This was also illustrated by her BMI which falls within the overweight range of 25-29.9. According to Williamson (2017), excessive weight is linked to various conditions such as asthma, diabetes, high blood pressure and heart disease. Additionally, the author states that being overweight is also associated with the polycystic ovarian syndrome as it worsens a woman's insulin resistance (Williamson, 2017). Another health risk uncovered during the assessment is the patient's high blood pressure which is above the normal levels. High blood pressure poses a great health risk as it is linked to heart attack and stroke. Further, the patient's blood glucose levels indicate that she is in the initial stages of diabetes, a condition that is potentially fatal.
Healthy Behaviors Identified
Despite the health risks unveiled during the assessment, it was notable that the patient also engages in healthy behaviors which are key to health promotion. These behaviors include controlled diet and engaging herself in physical exercise. Another healthy behavior that was discovered during the assessment is that of getting regular medical care which is vital to ensure a disease is detected at an early stage and hence easily controlled.
Based on the findings of the assessment, various recommendations can be made regarding the health promotion of each of the assessed body systems and hence the quality of life. Starting with the overweight problem, a number of interventions can be suggested. Some of the recommended interventions for excess weight include physical activity, lifestyle modifications such as proper diet, and psychological interventions. According to a study by Sherry et al. (2011), physical activity is considered the primary overweight intervention. Thus, frequent exercises would help the patient lose some weight and achieve the normal BMI. Exercise interventions combined with dietary interventions that target reduced energy intake would help the patient lose more weight because physical interventions often target increased energy expenditure (Williamson, 2017). Further, psychological interventions would play a key role in reducing psychological hurdles to health behavior change and maintenance. Some of the recommended psychological interventions include psychodynamic therapy and relaxation therapy, which would give psychological outcomes such as reduced depression and disordered eating. This would have an overall positive impact on the patient's quality of life.
Regarding the patient's high blood glucose, it is recommendable that her eating habits, for instance, Kaufman (2004) found that meals with high quantities of fat may result in prolonged blood glucose elevations after eating. Therefore, the patient can work closely with a dietitian to enable her to make the right food choices and quantities. This can also be combined with exercise as it would help improve her cell's insulin sensitivity while burning excess glucose for energy (Williamson, 2017). To reduce the patient's high blood pressure, lifestyle changes would be highly recommended while taking medicines as well. Lifestyle changes would entail getting more active, losing weight, and eating less sodium. Studies have shown that reduced weight, more physical activities along with reduced sodium intake can help lower a patient's blood pressure (Kaufman, 2004).
Based on the assessment findings, an overall plan for health can be developed. The plan consists of three major parts namely, what matters to one's health and what they are willing to do, anticipated goals and finally the steps that will help achieve the set goals.
What matters to my health and what am I willing to do within my ability?
Here, the patient should identify the barriers to taking care of their health. For example, lack of time could be a major barrier to many. To overcome the barriers...
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