Biographical Data
Comprehensive health assessment are done to evaluation an individual current, past, and potential medical health problems in order to effectively treat people. The person who I am performing health assessment is a 26 year old male, who recently was admitting to our local community hospital for severe abdominal pain. He is Hispanic who lives with his older sister. Have 2 small children who lives with their mother in a different residents.
Family Past Medical History
Patient’s past medical history are diabetes mellitus, hypertension, current smoker who smoke about 4-5 cigarettes a day. Patient was admitted for stomach pain, nausea and vomiting for the past 10 days. To start, the patient family history is his mother who is 49 years old, have diabetes mellitus, coronary artery disease, and hypertension. Next his father who is 53 years old, have history of hypertension, COPD, a current smoker and have asthma. His sister is 28 years old who also has asthma.
System assessment
Patient is alert and oriented to self, time, person and situations. Right and left pupils are round, size 3 and brisk. Mucus membrane is moist, minimal oral problem, no missing teeth. Skin is intact, warm, dry color is appropriate for ethnicity. Abdominal is soft and flat. Bowel sounds are active and present. There are slight tenderness, and no guarding. Appetite has been decrease due to pain, nausea and vomiting. The last bowel movement was 4 days ago prior to his admission. Urinate in urinal; color of urine is straw, clear, no odor and he denied persistence and pain when urinating. Respiratory: lungs sound clear on right and left posterior, anterior, and at base. Breathing is normal, unlabored, chest expansion is symmetric, no complaint of shortness of breath. Circulations: Radial pulse moderately strong, pedal pulse strong, capillary refill on finger is brisk and less than 3 seconds. Musculoskeletal: Left and right upper extremities are strong, lower left and right extremities are also strong. He have steady gait and provide self care.
Nursing Diagnosis
Actual nursing diagnosis is Acute Pain. The patient reported pain persisted for the last 10 days, tenderness on abdomen during palpation, anorexia and malaise. Interventions for this patient to help relief pain are to maintain bed rest in comfortable positions, assess locations, and type of pain, and offer ice or warm compression.
The wellness nursing diagnosis is Readiness for Enhance Nutritional Metabolic pattern. Patient has small frame, weight 117 pounds, low body weight, and reported consuming inadequate nutrition. Patient states he eats once a day when he gets the time. To help patient reach wellness, I would discuss barriers to obtaining adequate food, referral for social service and dietitian to consult. Further I will provide education on meal planning and to eat at least 3 times a day.
Additionally, Risk diagnosis is risk for constipations. Patient fluid intake is decrease, inadequate diet of nutritional values such as fibers, and green leaf vegetable. Provide education on amount of fluid to consume each day in order to soften up stools and promote circulations. Next I will offer hand outs of food groups that contain high in fibers to reduce constipation.