NITIAL POST: COMPREHENSIVE HEALTH ASSESSMENT PATIENT #2
The patient profile I have been assigned is a 35-year-old white male with a history of morbid obesity with disabilities in a rural setting. This is a new patient whom I am assuming I have never met before. The first step is to build a relationship with the patient, this fosters trust between the nurse and patient. “A primary objective is to discover the details about a patient’s concern, explore expectations for the encounter, and display genuine interest, curiosity, and partnership. Identifying underlying worries, believing them, and trying to address them optimizes your ability to be of help” (Ball, J. W., et al. 2019). A thorough health history is important as it lays the groundwork to not only build a relationship, but to efficiently diagnose a health issue or illness, and treat these health issues and illnesses.
Communication with this age group needs to include non-medical jargon so the patient will understand the information presented. Medical jargon can be used but needs to be followed up with what the medical term means. Open ended communication is important to use, this gives the patient the ability to “fill in the blanks” with pertinent information. For example, asking the patient why they came to see you today, what health concerns they want to talk about, and keeping the conversation going by asking if there is anything else they would like to talk about. This can be added numerous times during the assessment to keep the patient talking about issues they may have.
Information needs to complete a health assessment can include, past medical history, family medical history, social history, present medications, lifestyle considerations like alcohol, drug use, and smoking history. A head-to-toe assessment also needs to be completed to determine if there are any other issues needed to address. This patient would need education regarding lifestyle changes needed related to obesity. A referral to a dietary consultant may be needed if the patient is ready to make changes to their diet. Patients who reside in rural areas have less access to nutritious foods due to distance needed to get to a store where they can buy these foods. Many rural areas have quick marts where people can get fast food, not necessarily nutritious foods.
Obesity can cause many other health risks including HTN, Diabetes, Joint issues, difficulty breathing, Sleep Apnea, skin issues like yeast infections, wounds, and Stroke. Obese patients can also have trouble with ADLs as the inability to care for themselves is common due to decreased energy and inability to complete personal cares. This patient is noted to have disabilities; this can be related to joint issues and inability to ambulate, bend, reach, and general muscular and joint problems.
In relation to a risk assessment, I would use preventative care including personal history, laboratory screening tests to rule out Diabetes, Prostate Cancer, Hypercholesterolemia, Infection, and a Comprehensive Metabolic Panel to determine if the patient had any blood related abnormalities and determine if the patient had any problems with kidney or liver function. I would also determine if the patient had any issues with Alcohol, Tobacco, or drug use as use of these can lead to disease. In my communication with the patient regarding these issues I would be sure to tell him I ask all my patients these questions. Sullivan, D.D. (2019) states, “Approaching these matters in a nonjudgmental, professional, matter of fact manner should enhance patient disclosure of sensitive information.”
Questions I would be sure to include in my health assessment:
1. How are you feeling today?
2. What would you like for us to do today?
3. What do you think is causing your symptoms?
4. What are your coping mechanisms when you feel sad, scared, or angry?
5. Do you have people in your life whom you can talk to?
I feel it is important to not only assess a patient’s physical well-being, but to also assess if they are happy with their lives and feel heard, happy, and involved in their own care.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). 1(1-21). St. Louis, MO: Elsevier Mosby.
MediLexicon International. (n.d.). Morbid obesity: Symptoms, treatment, and outlook. Medical News Today. https://www.medicalnewstoday.com/articles/320460#complicationsLinks to an external site..
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). 2(19-29). Philadelphia, PA: F. A. Davis.
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