Comprehensive Health Assessment: Case Study Analysis - HNN114

This health assessment report meticulously analyzes the case of Mrs. De Silva, a 76-year-old female admitted to the Emergency Medical Unit (EMU) with symptoms of dizziness, shortness of breath, and chest pain. The report begins by identifying subjective and objective data, including Mrs. De Silva's cardiac problems, arthritis, irregular heart rate, low blood pressure, and difficulty providing her medical history. It then uses a health assessment framework to highlight both normal and abnormal findings. The report identifies acute and potential problems, such as irregular heartbeat, urine disorder, and a lack of detailed past medical history, framing these issues as problem statements requiring further investigation. The analysis delves into the rationale behind using tools like electrocardiograms and assessing kidney and bladder function. The report stresses the importance of comprehensive and systematic assessments in nursing practice and the delivery of patient-centered care, referencing literature and potential interventions. It highlights the role of registered nurses in conducting thorough assessments, analyzing data, and communicating outcomes to ensure safe, high-quality patient care, including considering the psychological well-being of the patient and the importance of therapeutic effectiveness.

Running Header: Health Assessment
Name: VirpalKour Bhullar
Student ID: 218563129
Subject: HNN114 HEALTH ASSESSMENT
Word count: 1653
Pages: 10

Health assessment
Part 1: Step 1
Identification of Subjective and objective data
General description of Mrs De Silva Dizziness, Shortness of Breath, Central chest
pain, suffering from Arthritis and cardiac
problems, HR 72, BP 95/58 (low Bp), Weight
62 Kgs.
Subjective data Objective data
Chest discomfort: The most common sign of
heart problem if having discomfort inside the
chest. If an individual has a blocked artery or
he or she is having a heart attack then that
individual might have pain, tightness in the
chest, or even pressure. But the symptoms are
different for each individual. Normal structure,
not obsessed not skinny.
In most of the cases, it has been seen that a
woman is having a heart attack without having
any kind of chest pain.
Swollen Joints, Arthritis, KKDA, SOBOE:
shortness of breath, Unable to remember
medical history, Urination problem,
Heart rate: 72bpm –Irregular
Respiratory rate 18- irregular
Specific oxygen rate as noted 99%, Height 1 m
62 cm,
Weight 62 Kg
BMI normal , 23.6
Getting Exhausted Easily: These activities may
be like climbing the stairs or carrying any
normal weighted goods such as groceries from
the car
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Health assessment
Part 1. Step II
Health Assessment Framework
Normal Findings Abnormal findings
Breathing on stethoscope tubing Shape and configuration of Chest Wall
Rustling of paper gown on paper drapes
Person shivering
Neck muscles should be developed normally
Feeling dizzy or light-headed Confirm systematic chest expansion
Palpate the entire chest wall
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Health assessment
Part 2, Step 1:
Acute problems / potential problems identified in Patient
 A1 heart problems Mainly cardiovascular issue, identified problem as Arrhythmia Ulcer or cysts in renal system Un-noted medical history of the patient raising problem in identifying possible errors in
Patients
Part 2 Step 2
Problem statement 1: Irregular heart Beat- 72/mint is low to the patient. It would rise
several complications in the next steps of treatment.
1. Do you experience grasping in breath, shortness of breath while having a speedy work,
lot of task, while eating?
2. Do you experience any mild or severe chest pain anytime?
3. Is there any incidence your heart rate has increased in a high rate and you are feeling
stressed?
Part 2: Step 2
Problem statement 2: Urine disorder – De Silva faces problem in urine passing mostly in
morning.
1. What was your last urine time?
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Health assessment
2. Is there any discomfort while passing urine? Such as itching? Bad smell, dis-colour?
3. Have you noticed any inconsistence in the last week?
Problem statement 3: last information regarding treatment was not noted, it makes difficult to
understand the past history of the patient
1. Do you remember any allergy to any particular medicine?
2. Do you remember any heart problem that occurred in last 10 years?
3. Have you gone through any major surgeries in past 10 years?
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Health assessment
Part 3: Step 3
Problem Statement 1: Irregular heart rate has been noticed in De. Silva, it creates possible
problems and complications in later phrases.
Objective data and rationale:
 Electrocardiogram helps in measuring electrical activity if human being. It is a process in
which the electrical activity of heart over a period of time is used using the electrodes that
is placed over the skin.
 If the report is abnormal, it may sign as a precursor in medical emergencies, there can be
advanced arrhythmia. Being a nursing personal the duty is to determine the readings that
are needed for further treatments.
 Heart arrhythmia is irregular heartbeat, in this group of condition, the recorded heartbeat
is found either slow or too fast. It needs to be noted for further treatments.
Problem statement 2: Problem in urine passing, mainly in morning
 In this condition the health areas that are affected are Kidneys, bladders, prostate glands
etc. It can be caused due to obstruction in bladder, or might be in a non obstructive
problem, such as bladder muscle, nerve problem.
 According to the case study, De Silva is facing problem in urine passing since morning.
It might be due to kidney cysts. Renal cysts might be there, such as rounded fluid filled
products that are formed inside the renal tissue layer.
 There can be an obstructer in Urinary tract; additional issues can be there in bladder
control. It might happen the sphincter muscle is weak and it can create a rise in
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Health assessment
incontinency in urine passing. Accurate information is critical to provide the best service
by the RN to the patient.
 This might be inherited condition, as there are no earlier records found. As the patient is
also having low blood pressure, BP rate 98/58, it might end up to any other physical
disorder.
Problem Statement 3: Lack of earlier history of treatment
There is no evidence of earlier history, if there are any heredity disorders. There is little
information found on previous clinical check-ups.
It’s important for a RN to know the past history during any care offered. There might be past
complexities that need to know, otherwise it might be critical for the patient.
Contextual information is missing in this case; there might be history of substance abuse, there
can be allergies and there can be allergies. If this past information are not known to the nurses,
then there can be plausible care strategies that are in presence of the clinical presence.
Priorities of care need to be recognised as an appropriate intervention process, it is commenced
through the optimisation of the clinical outcome, clinical and family history of patient is also
necessary to understand the care strategy.
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Health assessment
Topic: “RNs accurately Conduct comprehensive and systematic assessments. They analyze
information and data and Communicate outcomes as the basis for practice.” –
The comprehensive and systematic assessments are considered as critical constituent of nursing
practices and it is essential for the provision of family as well as patient centred care. The
analyses have been done over the delivery of safe and high-quality nursing care from the
registered nurses. Data was accumulated from variously published literature, along with patient
observation. Apart from that, telephonic conversations were done to gather information from the
registered nurses. Written consent was also received to copy the medical records of the patients.
Ten registered nurses were interviewed in terms of completing the procedure (Kitson et al.
2013). Specialist nurses usually focus on medical therapy. In the case of primary care, it is
required to involve specialist cardiology care physician to support and ensure the secondary care.
It is the key responsibility of the nurses functioning as a connector between primary and
secondary care. From the analysis, it can be said that nurses are also able to prescribe drugs
during the time of emergency. Nurses can also suggest the patient various diagnostic services
(Greer et al. 2013).
In most of the cases it is found that the nurse should have knowledge in Echocardiography. This
is the most important test to identify if there is any kind of cardio dysfunction. Thus the nurse is
required to provide a high-quality echo. In order to determine the etiology of HF, exercise testing
and coronary angiography are required to be done by the registered nurses.
Activities and responses of the registered nurses:
Knowledge Skill Attitude
Assessment of various human
factors and other primary
safety design principles
Demonstrate impactful
utilization of technology that
helps to support safety and
quality
Value the contribution of
reliability to safety
Defining the profitability and
limitations of the safety
increasing technologies
Demonstrating effective
utilization of technologies that
help to identify the associated
Identifying physical
limitations in terms of human
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Health assessment
risk of a heart patient performance
Discussing effective strategies
to reduce the potential risk
Communicating observations
related to associate hazards
with the patient, families and
the health care team
Giving value to his or her own
role in terms of preventing
error.
Describing the families of the
patient regarding the
advancement of technology
related to the safety and
quality of health care being
provided to the patient
Responding appropriately to
the clinical team regarding the
information of the patient
100 % involvement in case of
selection, evaluation, and
implementation of strategies
regarding the treatment of the
patient
Identification of essential
information in terms of
providing proper patient care
Application of various
technologies to support safe
procedure of patient care
Proper documentation of the
patient care to monitor the
results of the provided
treatment
The analysis describes the delivery of quality nursing care to the patients having cardio logical
problems or heart diseases. Therefore, it can be said that quality nursing care means not only
physical care but psychological care as well. Consequently, quality care was also interpreted as
therapeutic effectiveness which provides positive impacts to the patients and thus helps to heal
fast. This also helps the patient to response physically and psychologically toward the illness,
safety, and satisfaction. Therapeutic effectiveness also helps to develop a positive connectivity
between the nurse and patient (Tappenden et al. 2013).
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Health assessment
Reference:
Tappenden, K. A., Quatrara, B., Parkhurst, M. L., Malone, A. M., Fanjiang, G., & Ziegler, T. R.
(2013). Critical role of nutrition in improving quality of care: an interdisciplinary call to
action to address adult hospital malnutrition. Journal of Parenteral and Enteral
Nutrition, 37(4), 482-497.
Greer, J. A., Jackson, V. A., Meier, D. E., & Temel, J. S. (2013). Early integration of palliative
care services with standard oncology care for patients with advanced cancer. CA: a
cancer journal for clinicians, 63(5), 349-363.
Kitson, A., Marshall, A., Bassett, K., & Zeitz, K. (2013). What are the core elements of patient‐
centred care? A narrative review and synthesis of the literature from health policy,
medicine and nursing. Journal of advanced nursing, 69(1), 4-15.
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