Assignment: Advanced Health Assessment
Assignment: Advanced Health Assessment
Health assessment is a systematic, purposeful, and interactive process where nurses apply critical thinking to analyze and synthesize collected patient information. Health assessment helps in recognizing patients’ strengths in promoting health and in identifying patients’ needs and clinical problems (Thornbory, 2013). Through health assessment, the patient’s responses to health problems and interventions are evaluated. This paper will give a reflection of my experience when conducting a mental health assessment on Ms. Tina Jones.
I conducted a thorough health assessment that obtained vital information on the chief complaints, history of presenting illness, family history, and social history. The history-taking helped in identifying contributing factors, relieving factors, and areas of health promotion. I also took a detailed review of systems that helped in identifying symptoms not mentioned in the chief complaint and coming up with differential diagnoses.
Nevertheless, I had a challenge asking relevant questions at the appropriate time. I jumbled up some of the questions by asking them at the wrong time, which made the interview disorganized to some extent. In my future assessments, I will follow an order when taking history and ensure that I have asked all the possible questions in every category before heading to the next one.
Positive findings from the health assessment include sleep disturbances, fatigue, irritability, restlessness, and difficulty maintaining concentration. The patient also had generalized anxiety, a low mood, and a feeling of helplessness, which contributed to a decline in school performance alongside other symptoms.
The question on aggravating factors helped to understand what exacerbated insomnia and anxiety episodes and factors that may have contributed to Insomnia. Question on relieving factors yielded vital information on the techniques the patient used to alleviate the symptoms and their effectiveness. It also helped to diagnose the underlying issue and to identify the treatment measures. In addition, the question of how the lack of sleep affected the patient’s daily life gave information on the severity of the symptoms and helped to diagnose and manage the condition.
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I would order a urine drug test to help identify if the patient’s symptoms are a result of drug abuse. Besides, illicit drug use is
associated with mental health conditions such as anxiety, sleep disturbances, and depressive disorder (Newman, Cho & Kim, 2017). I would also conduct depression screening to rate the patient’s depressive symptoms using patient health questionnaire 9 (PHQ-9) and GAD-7 to assess for generalized anxiety.
Differential diagnoses for this patient include Generalized Anxiety Disorder based on positive symptoms of sleep disturbance, restlessness, irritability, difficulty maintaining concentration, and fatigue (Newman, Cho & Kim, 2017). The second differential is Insomnia based on positive findings of difficulty initiating sleep, poor sleep quality, and a decreased need for sleeping (Ellis & Allen, 2019). The third differential is Major depressive disorder: Pertinent positive findings include a low mood, feelings of helplessness, fatigue, Insomnia, irritability, and difficulty maintaining concentration.
I conducted patient education by advising Ms. Jones to lower caffeine consumption and increase the intake of water and other fluids to help lessen the severity of Insomnia (Ellis & Allen, 2019). I taught her on anxiety reduction strategies such as relaxation, deep breathing, and guided imagery (Newman, Cho & Kim, 2017). Besides, I encouraged her to maintain a regular sleep and wake schedule as well as sleep hygiene strategies such as limiting caffeine from the afternoon, limiting fluid intake after dinner, reducing stimulating activities after 8 pm, and get out of bed when awakened during the night (Ellis & Allen, 2019). Furthermore, I educated Ms. Jones to reduce the intake of alcohol and depressant medications such as Tylenol and diphenhydramine. Additional patient teaching should include education on when she should seek emergent or specialized care, such as when she is experiencing feelings of hopelessness or self-harm. She will also need to be educated on how to monitor her symptoms and record insomnia and anxiety episodes with the associated factors.
I would not prescribe pharmacological treatment at this point but rather encourage the patient to use non-pharmacological measures. I would prescribe psychotherapy to help Ms. Jones change her thoughts and behavior to help relieve symptoms (Barkowski et al., 2020). I exhibited sound critical thinking by obtaining subjective patient data on her current health symptoms and health history. I asked primary interview questions to help identify the underlying problem and then asked further questions to assess the severity of the symptoms and the general condition of the patient.
What went well in your assessment?
What did not go so well? What will you change for your next assessment?
What findings did you uncover?
What questions yielded the most information? Why do you think these were effective?
What diagnostic tests would you order based on your findings?
What differential diagnoses are you currently considering?
What patient teaching were you able to complete? What additional patient teaching is needed?
Would you prescribe any medications at this point? Why or why not? If so, what?
How did your assessment demonstrate sound critical thinking and clinical decision making? sample paper attached covers actual assessment just needs to be reworded and book reference is Bickley, L. S. (2013). Bate’s guide to physical examination and history taking (11th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. Chapters 16 & 17