NUR 545 Final Project
Type: Research Paper
Subject: Advanced Health and Literacy Assessment
Subject area: Nursing
Education Level: Masters Program
Length: 7 pages
Referencing style: APA
Preferred English: US English
Spacing Option: Double
Title: Patient Write up and Health Promotion Recommendations
Instructions: your write up: you should have already conducted your interview and have a draft of the (subjective documentation), you will be writing up your physical exam (objective documentation), formulating your medical diagnosis (collaborative diagnosis). a collaborative diagnosis is one that is used and shared by the medical team (md, np, pa, dietary, etc.), creating your plan (remember to include the necessary content, not a nursing care plan) and then include your specific health promotion tool. writing expectations: use the provided write-up template, which is also located in the final project ii guide rubric. no first person writing. apa rules apply. i am looking for you to integrate the lessons and writing style you have learned from working within shadow health, the modules and announcements. i am looking for detailed, organized documentation (with the appropriate subjective/objective content headings).
Patient Writeup and Health Promotion Recommendation
Name
Institution
Patient Writeup and Health Promotion Recommendation
Patient identification
Name: D. A
Age: 54
Race: White
Gender: Male
Subjective Data
Chief Complaint (CC):
Patient presented to the clinic today with complaints of heart palpitations
History of Present Illness (HIP)
Mr. Drew is a 56 years old male who presents at the Cape Cod clinic today with complaints of heart palpitations. The patient reports that the heart palpitations started about a week ago, and he first noticed the symptom while he was at the gym. He states that the palpitations come and go, and each episode last about 10-15 minutes. He states that the palpitations are about a 7/ 8 out of a 0-10 scale, when he has it. He denies having palpitations during clinic visit. He describes the palpitations as “it feels like my heart is going to come out of my body”. He denies taking any medications to alleviate symptoms; he states that the palpitation goes away on its own. He reports that the palpitations are aggravated by increased activity and anxiety.
Medications
Patient is under no medication
Allergies
Penicillin-Patient gets a rash as an allergic reaction to penicillin
Past Medical History
Patient has in the past experienced sudden sensations of spinning, which is triggered mainly when the patient is in motion. Patient claims having dizzy spells, where he feels as if the world around him is spinning.
Social History
Patient works full time as a Truck Driver. Denies ever smoking tobacco. Drinks on weekend’s socially, about 3-4 drinks. Denies use of illicit drugs. Patient attends to the gym 3- 4 times a week.
Family History:
Mother: Hypothyroid. Hypertension
Father: Hypertension. Hyperlipidemia
Sister: is healthy at 41-year-old age
Maternal Grandmother: Hypertension. Hypothyroid. Hyperlipidemia
Paternal Grandfather: Died at age of 88 years old with an MI
Review of Systems (ROS)
General: No abnormal changes in weight, fatigue, weakness, fever, chills, and night sweats.
Head: No history of trauma or headaches
Eye: No changes in vision. He denies use of corrective lenses
Ears- No hearing loss, tinnitus, vertigo, discharge, or earache
Nose/Sinuses: No rhinorrhea, stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure
Mouth/Throat/Neck: No bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth.
Respiratory: No shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis, Influenza.
Cardiovascular: No chest pain. Reports new episodes of palpitations. No edema. No murmurs. No ever having an abnormal EKG. No cardiac history.
Gastrointestinal: No abdominal discomfort, tenderness, distention, ascites. NO constipation, diarrhea, dark or bloody stools. No changes in diet regimen. No heartburns, nausea, vomiting. Feeling bloated, increased burping or gas. Denies liver, spleen, pancreas, or any other GI problems.
GE: No dysuria, frequency, burning or changes in urination. No strong odor in urine. No kidney problems, UTIs or bladder incontinence
Musculoskeletal: No muscle weakness, joint stiffness, gait changes, pain, joint instability, or swelling. No difficulties with range of motion. Denies numbness, tingling, or radiation. No previous musculoskeletal injuries or fractures.
Neurologic: No loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, seizures, change in mental status, or memory changes.
Skin: No skin changes, jaundice, cyanosis, rashes, moles, bruises, wounds, or any open areas
Objective Data
Vital Signs- Temperature- 98.6 orally. RR- 18. O2 saturation reading- 100% RA. Heart Rate- 98. BP- 130/69. Weight- 102 kg BMI 28
General survey- Patient is alert x3. Well groomed. Well nourished. Good posture. Pleasant. Answers all questions appropriately and maintains eye contact throughout interview. No acute distress
Skin, nails and hair- Skin is pink, dry, thin, and warm. No cyanosis and no jaundice. Fingernails are rounded, pink and firm. No clubbing. Toenails are pink, flat and pink. No clubbing. Skin turgor- no tenting. Hair/scalp- well distributed. No masses, no lesions palpated
Head and Face- Normocephalic and atraumatic. Temporal artery +2 bilateral. No thrills, or bruits. TMJ- no clenching.
Eyes- Bilateral equal hair distribution. No edema. No lesions or ptosis. Conjunctiva is pink and moist. Extraocular movements are intact bilaterally. Pupils are reactive to light and accommodation bilaterally. Fundoscopic exam- sharp disc margins. No hemorrhages. Normal convergence. Vision 20/20 bilaterally. Peripheral vision intact bilaterally
Ears- Ear shape is pink and symmetric bilaterally. External canal without inflammation bilaterally. Tympanic membranes are pearly gray and intact. No discharge, no fluid or cerumen. Some hair noted. Rinne, whisper and Rhine test normal bilaterally.
Nose- Nares are pink. Septum midline. No deviation. No swelling, drainage, and no erythema. Turbinate patent bilaterally. No pain on frontal or maxillary sinus when pressed. Sense of smell is intact bilaterally
Throat/ mouth- Lips is pink, moist and symmetrical. No wounds or sores. Teeth are white, well kept. No dental caries visible. Tongue is strong and midline. Oral mucosa is moist and pink. Uvula is midline. Tonsils are +1 bilateral, No swallowing or signs of inflammation. Gag reflex intact.
Neck- Symmetrical. No masses or swelling. No swollen lymph nodes or palpable. Thyroid glands without nodules or goiter.
Cardiovascular- tachycardic- RH of 98, S1 and S2 present, no murmurs, rubs, gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thrills. No temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. No JVD. Capillary refill < 3 seconds. No peripheral edema. EKG with regular sinus rhythm, no ST changes.
Cardiovascular- tachycardic- RH of 98, S1 and S2 present, no murmurs, rubs, gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thrills. No temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. No JVD. Capillary refill < 3 seconds. No peripheral edema. EKG with regular sinus rhythm, no ST changes.
Respiratory- Chest is symmetrical with respirations; no physical abnormalities present on chest wall. Expected Fremitus. Lung sounds clear to auscultation without wheezes, crackles, or cough. No dullness on chest percussion. Bronchophony is positive. Unlabored respiration at 18. O2 saturation is 100 % at room air
Abdominal- Abdomen is soft, rounded, without scars or skin lesions. Bowel sounds present and normoactive in all quadrants. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. No CVA tenderness
Musculoskeletal- Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper extremities with full range of motion of shoulder, elbow, and wrist. No evidence of swollen joints or signs of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Bilateral upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles. Spine is midline, no signs of scoliosis. Full ROM.
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Neurologic- Sense of smell intact and symmetric. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Abstract thinking, attention, comprehension intact. Short- and long-term memory intact. Cranial nerves, 1,2, 3, 4, 5, 7, 8, 9, 10, 11 and 12 intact. Stereognosis and graphesthesia intact bilaterally.
Laboratory Tests
CBC test: this blood test is used in the evaluation of an individual’s overall health and it aids in the detection of an extensive range of diseases; this includes anemia (Jimenez, Kulnigg, & Gasche, 2015). If the outcomes from the routine CBC test reveals that the patient’s hematocrit and hemoglobin levels are low and his RBC are paler and smaller (hypochromic and microcytic) than usual, iron tests may be ordered (Jimenez, Kulnigg, & Gasche, 2015). Some of the commonly ordered iron tests include
- Serum iron test: this test measures iron level in the blood’s liquid portion.
- Transferrin test: it directly computes transferrin levels in the blood. Transferrin, according to Jimenez, Kulnigg, and Gasche (2015), is the protein that carries or transports iron throughout the body.
- Total iron-binding capacity (TIBC): This particular test is used to measure the total level of iron bound by blood proteins. This particular test can be used to indirectly evaluate the availability of transferrin (Jimenez, Kulnigg, & Gasche, 2015).
- Unsaturated iron-binding capacity (UIBC): this test is used to ascertain transferrin’s reserve capacity (Jimenez, Kulnigg, & Gasche, 2015).
- Transferrin saturation: a computation that reveals the percentage/rate of transferrin saturated with iron (Jimenez, Kulnigg, & Gasche, 2015).
- Serum ferritin: reveals the level of stored iron within the body.
TSH test: This is the initial test ordered by practitioners to detect the presence of thyroid dysfunction (Leo, Lee, & Braverman, 2016). If test results reveal abnormal levels of TSH, free thyroxine (free T4) test and free T3 test will be done to confirm the diagnosis (Leo, Lee, & Braverman, 2016). This will be done using immunoassay.
Electrolyte test: This will be done using an electrolyte panel, which measures or computes the blood levels of the major body electrolytes (Balci, Koksal, Kose, Armagan, & Inal, 2013). These electrolytes include bicarbonate, chloride, potassium, and sodium (Balci et al., 2013).
Medication
Propylthiouracil (Rx), (50mg), 300-450 mg/day PO divided q8hr initially (may require up to 600-900 mg/day)
Maintenance: 100-150 mg/day divided q8h
Propranolol (Rx) IV: 1-3 mg at 1 mg/min initially; repeat q2-5min to total of 5 mg
Once maximum dose or response is attained, do not give additional dosage for a minimum period of 4 hours
Nutrition
Increase water intake
Avoid caffeinated foods and beverages
Teaching
Patient education began during the assessment phase and it went on until the patient was discharged from the hospital. Some of the common elements incorporated during this session include signs and symptoms of hyperthyroidism, the diagnosis of the disorder, the management and treatment options, and the self-efficacy approaches associated with the disorder. The patient was also given a brochure that detailed all the aforementioned information.
Follow Ups
The patient should make a follow up visit after 14 days (7/03/2020). The aim of the follow up visit is to ascertain the efficacy of the therapy in the management of the disorder (hyperthyroidism).
Diagnosis
Electrolyte Imbalance
Water-electrolyte imbalance, commonly referred to as electrolyte imbalance, refers to the abnormal electrolyte concentration within the body. Electrolytes, according to Balci et al. (2013), play a crucial role in maintaining the process of homeostasis in the body; they aid in enhancing the regulation of acid-base balance, oxygen delivery, fluid balance, neurological function, and heart function. Electrolyte imbalances can result from the excretion of too much or too little electrolytes as well as the consumption of too much or too little electrolyte (Balci et al., 2013). The causes and severity of these particular disturbances can differ significantly depending on the affected electrolyte. The patient may be experiencing palpitations as a result of an electrolyte imbalance. This diagnosis is based on the fact that the patient experiences the palpations after exercising or after participating in a physically tasking event. This is common among men in his age group.
Hyperthyroidism
The patient’s chief complaint is heart palpitations, which is a common symptom associated with hyperthyroidism. According to Leo, Lee, and Braverman (2016), numerous patients with hyperthyroidism typically report symptoms associated with the heart. The most reported heart-related symptoms by patients diagnosed with hyperthyroidism include heart palpitations and racing heartbeats. The aforementioned symptoms often occur because of the physiologic impact of thyroid hormone on the heart. Excess thyroid hormone triggers palpitations and a significant level of exercise intolerance as a result of fatigue and increased heart rate. Heart rate changes, according to Leo, Lee, and Braverman (2016), may result from the change or modifications in the nervous system’s capacity to regulate the normal functioning of the heart. With the significant increase in the level of thyroid hormone in the body, a heart rate of over 90 beats per minute (tachycardia) is expected; this may also occur when one is asleep or at rest. Furthermore, the typical heart rate increase during exercise may be exaggerated (Leo, Lee, & Braverman, 2013).
Anemia
Heart palpitation is also a common symptom reported by patients diagnosed with iron deficiency anemia. Anemia, according to Jimenez, Kulnigg, and Gasche (2015), is a medical condition typified by a less than usual hemoglobin level or RBC count. Some individuals diagnosed with anemia; especially mild anemic conditions may not have any anemic-related symptoms; they are asymptomatic. However, whenever symptoms occur, the most reported symptoms include heart palpitations, dyspnea, worsening heart conditions, skin discoloration (appears pale), fatigue, and tiredness (Jimenez, Kulnigg, & Gasche, 2015).
Health Promotion Tools
There are three primary health promotion tools used in preventive care; they include health communication, health education, and systems, policy and environmental change (Razmara, aghamalai, Madani, Hosseini, & Zare, 2018). Health communication incorporates the use of both written and verbal approaches to empower and influence communities, populaces, and people to make healthier choices. Effective health communication strategies include
- The utilization of research-based approaches to and design products and materials and to select delivery channels for these products to the intended audience (Jia, Fu, Gao, Dai, & Zheng, 2018).
- Comprehension of conventional priorities, language, conceptualizations, and wisdom for different settings and cultures.
- Consideration of cultural competency, media exposure, internet access, and health literacy of target populaces (Jia et al., 2018).
- Development of materials, for instance, brochures and pamphlets (Jia et al., 2018)
Health communication approaches aim to transform people’s behaviors, attitudes, and knowledge. For instance, it can aid in increasing risk perception, influence social norms, reinforce positive deportments, increase availability of needed services and support, and empower people to improve or change their health conditions (Jia et al., 2018).
Health education offers learning experiences on various health topics. According to Razmara et al., 2018), health education approaches are typically tailored for specific/target populaces; it presents data to target populaces on various topics, for instance, threats faced by the target population and the benefits of health promotion. Furthermore, it offers tools used to build the ability and support for behavior change (Razmara et al., 2018).
Lastly, systems, policies, and environmental change are structure to promote or foster healthy behaviors by enhancing the easy accessibility and availability of healthy choices within the community (Jia et al., 2018).
Recommended Health Promotion Tool
I recommend the use of health communication tools, particularly brochures; this particular approach will play a crucial role in promoting health maintenance and improving patient outcomes. According to Jia et al. (2018) the selected approach can aid in increasing the patient’s risk perception, influencing social norms, reinforcing positive deportments, increasing the availability of needed services and support, and empowering the patient to improve or change their health conditions (Jia et al., 2018).
Theoretical Models
The theoretical model of nursing, health literacy, and health promotion I applied during the health assessment process is the health belief model. This model, according to Razmara et al., (2018), can be utilized to guide disease prevention and health promotion approaches during different stages of care delivery. I chose this particular theoretical model because its primary elements focus essentially on a person’s or patient’s belief concerning his health condition, which consequently predict his health-related behaviors (Razmara et al., 2018). The knowledge concerning a patient’s health-related behaviors can help practitioners initiate approaches that aim to improve the patient’s outcomes and enhance the health maintenance. The model, according to Razmara et al., (2018) defines primary features that impact health behaviors as perceived susceptibility, perceived severity, perceived benefits, cues to action, perceived barriers to action, and self-efficacy. The implementation of this particular model involves five primary steps. These steps include
- Gathering data by carrying out a health needs assessment and other approaches to ascertain the patient’s risk of exposure.
- Conveying the consequences of the identified health issues linked to risk behaviors in a vivid and unambiguous manner to comprehend perceived severity.
- Communicating to the patient the steps involved in implementing the recommended action and underscoring the benefits to action.
- Offering assistance in distinguishing and minimizing action barriers.
- Demonstrating/exhibiting actions via skill development approaches and providing support which fosters self-efficacy and the probability of successful behavioral changes.
Cultural and Environmental Factors
Some of the cultural and environmental factors that will play a crucial role in influencing the provision of care to my client include the patient’s social economic status, for instance, income education and occupational status, social network and social support, and his psychosocial work environment. According to Jia et al., (2018) social and environmental variables potentially impact patients’ health outcomes all through the entire etiology spectrum i.e., from the onset of the disease to disorder progression to survival. During every phase of the disorder continuum/spectrum, social-environmental variables can impact outcomes in several ways. Before the disease onset, social variables might affect the risk of infection, the capacity to cope with severe/adverse circumstances, or the adoption of health-promoting and risky behaviors (Jia et al., 2018). Consequent to the onset of the disorder, social variables may ascertain the progression rate of recovery/disease through different rates of coping behaviors, treatment adherence, treatment access, or direct impacts on tissue repair and immune surveillance (Jia et al., 2018).
Informatics
Role of Informatics in Completing Comprehensive Health Assessments
Informatics is revolutionizing healthcare. With the advancement of technology, healthcare providers and organizations have the ability to analyze, leverage, and collect data in a more effective way (Feldman, Buchalter, & Hayes, 2018). It has been the case primarily when it comes to nursing, resulting in a better provision of healthcare. When it comes to health assessment, informatics has improved nursing when it comes to documentation. For instance, my notes during the health assessment were made electronically, which keeps records up to date and ensuring records are easily accessible. It enhances client care since one does not need to leave the room in order to fetch patient records. Advancement in informatics will have an impact on me as a master’s prepared nurse in that it will facilitate the efficient coordination and interpretation of patient information between me and other healthcare professionals for instance, other nurses, physicians, and surgeons.
References
- Balc?, K., A., Koksal, O., Kose, A., Armagan, E., Ozdemir, F., Inal, T., and Oner, N., (2013). General Characteristics of Patients with Electrolyte Imbalance Admitted to Emergency Department. World Journal of Emergency Medicine, 4(2), 113–116.
- Feldman, S., S., Buchalter, S., and Hayes, W., L., (2018). Health Information Technology in Healthcare Quality and Patient Safety: Literature Review. JMIR Medical Informatics, 6(2), e10264.
- Jia, J., Fu, H., Gao, J., Dai, J., and Zheng, P., (2018). The Roles of Health Culture and Physical Environment in Workplace Health Promotion: A Two-Year Prospective Intervention Study in China. BMC Public Health, 18, 457.
- Jimenez, K., Kulnigg-Dabsch, S., and Gasche, C., (2015). Management of Iron Deficiency Anemia. Gastroenterology Hepatology, 11(4), 241–250.
- Leo, D., S., Lee, Y., L., and Braverman, E., L., (2016). Hyperthyroidism. Lancet (Author manuscript), 388(10047), 906–918.
- Razmara, A., Aghamolaei, T., Madani, A., Hosseini, Z., and Zare, S., (2018). Prediction of Safe Driving Behaviours based on Health Belief Model: The Case of Taxi Drivers in Bandar Abbas, Iran. BMC Public Health, 18, 380.
