Advanced Health Assessment Case Study

This report discusses the identification of two health assessment areas based on a given case study of a 16-year-old adolescent suffering from severe abdominal and pelvic pain. It includes a description of the case study, past medical history, nursing assessment, pain assessment, and two health priorities for the patient. The report concludes with a brief on the advanced health assessment areas and the importance of proper planning, implementation, and outcome.

Advanced Health Asessment
Case Study

TABLE OF CONTENT
INTRODUCTION...........................................................................................................................3
MAIN BODY..................................................................................................................................3
Description of case study.............................................................................................................3
Past Medical History....................................................................................................................3
Nursing assessment......................................................................................................................4
CONCLUSION................................................................................................................................7
REFERENCES................................................................................................................................1

INTRODUCTION
Advance health assessment is the systematic procedure for analysing and evaluating the
physical, mental and each functional areas of the patient health from where an individual can get
the proper treatment in definite manner (Kim, Cho, Kim and et.al., (2018). This assessment area
includes all the diagnostic practices to identify the health status of the patient and can provide
them an actual better treatment and care. The present report will illustrate the identification of the
particular two health assessment area which is based on the given case study. The report will also
discuss the health priorities of individual person who is mentioned in the given case study report.
MAIN BODY
Description of case study
In the given case study report, a 16year old adolescent has been suffering form the health
issues where it becomes important to present her at the emergency department. Her name is
Cammy, and had a history of 3 days, where she is suffering from an abdominal pain and nausea.
An abdominal pain feels between the chest and groin and nearby stomach region or belly where a
severe pain develops suddenly and requires an emergency care. Looking at Cammy's medical
history, there is no previous surgical of important medical history apart from painful
mensuration. Whenever, Cammy feels a severe pain during her menses, she manages it with
using the naproxen sodium tablets directly from the chemist without consulting a doctor and
specialist (Li, Mah, Swami, Pope, Hannon and et.al., (2019). The mentioned drug is commonly
used for reducing the fever and relieving a mild pain from the headaches, muscle ache, common
cold, backache and even tooth aches along with mensuration pain as well. It is a powerful
painkiller in general, where Cammy used this drug or tablets during her periods to feel relieve
from the major stomach pain. The vital signs on the presentation has included the heat rates,
blood pressure, pain scale and score, oxygen saturations and such more.
Past Medical History
The past medical history of a 16-year-old girl Cammy, reflects her abdominal pain
condition and also suffering from nausea where there is no such significant operational health
history has been founded in the medical report. She only takes some medicines name naproxen
sodium while she feels pain during her periods to reduce the pain where this drug is only a
common pain killer for severe pain. Her hear rate is 100 beat/minute which means it is higher
than the normal HR which is 72 beat/minute and respiratory rate is 20per minute where the

standard RR is 12-20. The blood pressure has been also mentioned where 110/65 mm Hg where
a standard BP for an adolescent should be 110/70 mm Hg and temperature is 37. 6 0C. Also, her
oxygen saturations are 99% on normal room air and her pain score is 9/10. In the report, it has
been mentioned that Cammy is diaphoretic where it means excessive and abnormal sweating in
the environment which overall affects the body of the patient. It is generally a cold sweat state
which Cammy is suffering from.
Nursing assessment
Assessment
The term assessment simply refers as an analysis and identification of the particular
health issue which is suffering by the girl Cammy as per the given case study. She is suffering
from an abdominal and pelvis pain where at first, it is required collecting and gather the
appropriate data and information of the past medical history of the adolescent from where a
proper diagnostic function can be performed. According to Zou, Huang and et.al., (2018) in the
abdomen pain issue, doctors are required to detect the disease of the small bowel, colon and
other internal organs where a proper issue can be identified. Abdomen and pelvis pain can be
interrelated with each other as cause of the pain could be related to small bowl obstruction,
tumours and cancers, constipation, femoral hernia, umbilical hernia, abdominal aortic aneurysm
and even a pregnancy. According to the case study, Cammy is feeling a pain in abdomen and
pelvis where a proper inspection would be a first step which will help to know and understand
the actual health issue which is causing and affecting the Cammy body.
Diagnosis
The second step is diagnosis where a clinical judgement occurs for the proper planning
and implementation of the patient care. A diagnostic test is managed by the health assessor or
doctors where a particular procedure is conducted to help diagnose the cause of abdomen and
pelvic pain. Accordingly, the ideal position of the abdominal is to sit or kneel on the right side of
the patient with the hand and forearm in same horizontal position (Öztürk, Sevil, Sargin, &
Yücebilgin, (2018). Possibly, an appendicitis, UTI and irritable bowel syndrome can be a reason
for the abdominal pain. For evaluating or diagnosing the abdominal pain, blood test, urine test,
CT scan or ultrasound tests are essential where in the looking at pelvic pain, lab test and
laparoscopy is requires in essential and required manner as per the condition of the patient. A
proper test should be done from where Cammy health condition and reason of pain can be

identified in definite manner (Butterly, Siegel, Fedewa, Robinson and et.al., (2021). As per the
case study, it has been given that she used to take drug of pain killer during her mensuration
where an infection or inflammatory bowel disease can be occurred such as ulcerative colitis or
Crohn's disease or even a liver cirrhosis.
Planning and Implementation
Planning and implementation is the process where a goal has been set and perform an
activity for the further success of the treatment from where a patient can get the treatment and
care in appropriate manner. According to the case study, a proper planning for the
implementation of the diagnosis is to be done from where nurses and doctors can be able to
understand the cause of the abdominal and pelvic pain. For the implementation, different types of
test is required to be done which will let know the symptoms and a particular issue which is
affected the Cammy's body. All the metal materials has to be removed from the Cammy's body
for the CT scan which will help to know the internal injuries and damages and also can evaluate
the pregnancy outcome. Implementing the CT scan procedure, it will help to examine the body's
function in definite manner (Garber, Frakes, Arora & Chahal, (2018). However, according to the
case study, it has been founded that Cammy get hurt and pained during her periods in greater
manner where it can be due to endometriosis which is a primary symptom of pelvic pain and
abdominal pain which is associated with menstrual periods. In the endometriosis, pain during
mensuration, pain in lower abdomen, lower back, pelvis, rectum and vagina occurs in greater
manner and leads the person to suffer from sever pain where accordingly, Cammy is also
suffering from same. As per the results and outcome, it should be a disease endometriosis which
is felt by Cammy where she requires a perfect and appropriate treatment to reduce and recover
the disease in definite manner.
Evaluation
In the evaluation process, a positive and negative aspects has to be considered according
to the nursing interventions where a final outcome can be determined in actual manner. The issue
has been diagnosed in effective manner where it has been evaluated that Cammy is suffering
from endometriosis disease or a problem where it has been founded through different kinds of
test and scan at the nursing interventions process. Implementation of the different test allowed
the nurses and doctors to identify the particular disease as per the symptoms they noticed and
enabled them to apply a proper treatment and care to Cammy. Also, in her past medial history it

has mentioned that she would take some medicines for reducing her menses pain where it can
also be a reason of her severe abdominal and pelvic pain. Accordingly, by the diagnosis and
planning process, it has been evaluated that Cammy is having an issue of endometriosis where
women get painful periods, and an excessive bleeding sometimes where it causes them a major
pain in pelvic and abdominal areas (Bullock, Bedson, Jordan, Bartlam, Chew‐Graham and et.al.,
(2019). A proper medication is also required to be given to Cammy which will make her to feel
better and can implement a treatment and care in successful manner. OCPs, progesterone and
medroxyprogesterone acetate should be used for the first line therapy for treating pain.
Pain assessment
Palliative: When, Cammy visited to hospital for the treatment in emergency department, firstly
doctor has read out the past medical history of Cammy and gave her an injection for the pain
relief and leave her to take a proper rest until they find out the actual cause as they cannot treat
the person without identifying the actual cause of the sever abdominal pain.
Quality: Cammy was feeling sharp and throbbing, and she was not able to feel comfortable and
her heart rates was 100/beats per minute, BP was 110/65 mm Hg and RR was 20 breath per
minute where it has been cleared that she was feeling severe pain.
Radiation: The pain was in abdominal and pelvis where it was hurting her in larger manner and
giving the pain as restless condition.
Subjective Description: Cammy was getting pain in wider basis, as per the severity scale the rate
of the scored as 9/10 which means she was is very critical condition and needed a quick
treatment and care.

Time: She was having a pain from last 3 days, where according to the current situation as per the
case study, she is not able to tackle and handle the pain in appropriate manner and leads her to
feel nausea as well.
Two health priorities for Cammy
 Eat slowly and avoid eating food which cause difficulties in digestion
 Avoid trans fats
 Limit of caffeine and alcohol
 Eat plenty of fruits
 Take a quick walk after eating and regular exercise
CONCLUSION
The current report has concluded the brief about the advance health assessment areas
where a proper planning to implementation and outcome should be achieved in successful
manner. The report has conducted the health assessment based on the given case study where an
adolescent was suffering from a severe pain in abdomen and pelvis where a critical and
identification of the main cause has been founded and provided a complete patient review. Also,
it has involved the pain assessment with the scale and mentioned the priorities of the health for
the given individual.

REFERENCES
Books and journals
Bullock, L., Bedson, J., Jordan, J. L., Bartlam, B., Chew‐Graham, C. A., & Campbell, P. (2019).
Pain assessment and pain treatment for community‐dwelling people with dementia: A
systematic review and narrative synthesis. International journal of geriatric
psychiatry. 34(6), 807-821.
Butterly, L. F., Siegel, R. L., Fedewa, S., Robinson, C. M., Jemal, A., & Anderson, J. C. (2021).
Colonoscopy outcomes in average-risk screening equivalent young adults: data from the
New Hampshire Colonoscopy Registry. Official journal of the American College of
Gastroenterology. ACG, 116(1), 171-179.
Garber, A., Frakes, C., Arora, Z., & Chahal, P. (2018). Mechanisms and management of acute
pancreatitis. Gastroenterology research and practice. 2018.
Kim, M. J., Cho, J. S., Kim, E. M., Ko, W. A., & Oh, J. H. (2018). Optimal time interval for
surgery after neoadjuvant chemoradiotherapy in patients with locally advanced rectal
cancer: analysis of health insurance review and assessment service data. Annals of
Coloproctology. 34(5), 241.
Li, B., Mah, K., Swami, N., Pope, A., Hannon, B., Lo, C., ... & Zimmermann, C. (2019).
Symptom assessment in patients with advanced cancer: are the most severe symptoms
the most bothersome?. Journal of Palliative Medicine. 22(10), 1252-1259.
Öztürk, R., Sevil, Ü., Sargin, A., & Yücebilgin, M. S. (2018). The effects of reflexology on
anxiety and pain in patients after abdominal hysterectomy: a randomised controlled
trial. Complementary therapies in medicine. 36, 107-112.
Zou, X., Huang, H., Yang, L., Liu, H., Li, Y., Xia, Q., ... & Yao, S. (2018). Methamphetamine
consumption and life-threatening abdominal complications: a case
report. Medicine. 97(18).
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