Case
NUR-643E Health Assessment Check Off Project
- Course
- NUR 643E
- Institution
- Grand Canyon University
NUR-643E Health Assessment Check Off Project
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Running head: HEALTH ASSESSMENT CHECK OFF PROJECT 1NUR-643E
Health Assessment Check Off Project
Advance Health Assessment
Grand Canyon University
Health Assessment Check Off Project
NUR-643E
Introduction
Nursing health assessment is an incredibly valuable tool nurses have in their arsenal of skills. A thorough and skilled assessment allows the nurse, to obtain descriptions about the Running head: HEALTH ASSESSMENT CHECK OFF PROJECT 2
patient’s symptoms, how the symptoms developed, and a process to discover any associated physical findings that will aid in the development of differential diagnoses. Assessment uses both subjective and objective data. Subjective assessment factors are those that are reported by the patient. Objective assessment data includes that which is observable and measurable (Jarvis, 2012). A complete history will serve as a guide to help identify potential or underlying illnesses or disease states. Once assessment and planning have been completed, including analysis of the collected data, the next step is implementing the strategies and interventions that will comprise the health program. The purpose of obtaining a health history is to provide us with a description of the patient’s symptoms and how they developed (Bickley & Szilagyi, 2017). A comprehensive
health history is pertinent in healthcare settings to provide high-quality patient centered care, prevent medical errors, ensure patient safety, and prevent mortality and morbidity with timely detection of diseases. Health interviews open a path to understand the patient’s needs, prioritize the patient care and medical management, and identify any medical emergencies. It gives a picture of the patient’s current health, behavior, and risk status. (Bickley and Szilagyi, 2017
Physical Exam Documentation
Chief Complaint: Patient says I am here with lower back pain for one week. There was no other prior history of back pain. Increasing in pain intensity for 5 days. Rated pain score 8/10, no
prior history of trauma or sprain, walking and climbing the stairs aggravated the pain, the pain was relieved by resting, and the lower back pain had affected her daily living activities.
History of Present Illness: Mr. Bob is a 65 year Asian American came in independently with intense intermittent lower back pain in both lower extremities along with numbness and tingling on and off. Also, I feel my legs are very cold all the time. with a complaint of low back pain,
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