Health Assessment Report: Analyzing Mr. Williams' Case Study

This report presents a comprehensive health assessment of Mr. Williams, a 48-year-old patient admitted after a fall. Part A details observed signs and symptoms, including neurological, cardiovascular, respiratory, and psychosocial aspects. Part B identifies and analyzes nursing problems such as pain, fluid and electrolyte imbalance, anxiety and stress, withdrawal symptoms, and potential movement of bone fragments, along with assessment plans and rationales. Part C explores nursing assessment frameworks, comparing the biomedical and functional approaches, highlighting their advantages and disadvantages, and concluding with the importance of a comprehensive assessment for future nursing practice. The report references relevant literature to support its findings and recommendations, providing a holistic view of patient care and assessment strategies.

HEALTH ASSESSMENT 1
Health assessment
Student Name
Institution
Date

HEALTH ASSESSMENT 2
Health assessment
Part A
Signs and symptoms
Neurological CNS Severe to moderate pain
Cardiovascular CVS Regular heart and rhythm rate, Blood
pressure 150/20, temperature 37.8 degrees
Celsius heart rate 105
Respiratory Oxygen saturation 94%, respiratory rate 25,
history of smoking at least 20 cigarettes in a
day
Genitourinary No data available
Musculoskeletal Right arm supported in sling, fractured rib,
dislocated shoulder, bruising on the right
upper thigh, very little movement
Gastrointestinal No known drug allergies
Integument A lot of sweat
Endocrine or metabolic Sweating and appears pale
Psychosocial Possible withdrawal symptoms due to lack
of smoking cigarettes

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Part B
Nursing problem Rationale
Pain Administration of analgesics like morphine,
injectable drugs like Toradol (ketorolac) or
muscle relaxants help to relieve bone pain
and have a longer action.
Fluid and electrolyte imbalance An imbalance in the fluid and electrolyte
causes excessive sweating. This imbalance
may delay bone growth and the rate of
healing
Anxiety and stress Encouraging the patient to discuss problems
that relate to the fall, may help to reduce
anxiety. Reliving the accident experience
helps the patient to cope and come to terms
with the reality
Withdrawal symptoms Most hospitals do not allow smoking. The
patient may be facing withdrawal symptoms
from the lack of tobacco intake. This is
visible through the sweating, paleness and
muscle spasms
Movement of bone fragments Any movement to the dislocated shoulder or
broken ribs increases the risk of more
physical injury. It also slows down the
healing process.
Nursing problem Assessment plan Rationale evaluation criteria
or assessment
findings
Pain Three open-ended
questions
- Using a scale
of 1 to 10,
which
number best
describes
your pain,
with 1 being
moderate and
10 being
- Using the
scale it is
possible to
self-report in
order to
administer
the correct
medicine
- This
The patient reported
a pain level of 4/10
Morphine had been
effective in reducing
the pain
The patient-reported
no other underlying

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acute?
- is the
morphine
effective?
- How are you
feeling
today?
Further assessment:
- Observe the
nonverbal
cues such as
aggravation,
change in
emotions,
crying and
the need for
consolation
establishes
the
effectiveness
of morphine
- It helps to
identify other
underlying
symptoms
Nonverbal cues can
also help in an
objective analysis of
the pain level
symptoms
Nonverbal Cues
showed that the
patient is in
moderate pain
Electrolyte and fluid
imbalance
Three open-ended
questions
- how do you
feel?
- are there any
new
symptoms
since the last
check up?
- do you feel
dizzy?
Further assessment
- blood sugar
levels and
blood
pressure
should be
analysed
This helps to analyse
the extent of the
electrolyte and fluid
imbalance in the
body
Analysis of the
blood sugar and
blood pressure
shows the levels of
the imbalance
The patient reported
sweating
Blood pressure was
normal; however, the
heart rate appeared
to be high.
Stress and anxiety Three open-ended
questions
- How did the
accident
make you
feel?
- what are
some of your
- this helps the
patient to
analyse some
of the
difficult
emotions.
The patient is able to
talk about the
accident
focusing on the
positive helps to
reduce the anxiety

HEALTH ASSESSMENT 5
fears?
- what are you
grateful for?
Further assessment
- a counseling
session will
be scheduled
- this question
helps the
health care
workers
know what to
address and if
there is need
for a
psychological
intervention
- focusing on
the positive
instead of the
negative
helps to
relieve the
symptoms of
anxiety
A counsellor may
help to identify other
underlying problems
level
The psychologist
confirmed that there
was no need for
further counseling
sessions
withdrawal
symptoms
Three open-ended
questions
- are you
addicted to
smoking?
- how long
have you
been
smoking?
- why do you
smoke?
Further assessment
- conduct test
- Admitting
that they
have a
cigarette
problem can
help in
controlling
the
withdrawal
this helps to
analyse the
damage
caused by
tobacco
smoking
- Helps to
identify the
root cause of
the smoking
behaviour
- The patient
admitted that
they had a
tobacco
problem
- The patient
had been
smoking for
28 years
- The root
cause of
smoking is
unknown

HEALTH ASSESSMENT 6
to determine
if there is any
damage
caused by
tobacco
smoking
Helps to detect
underlying effect of
tobacco to the body
Movement of bone
fragment
Three open-ended
questions
- do you feel
pain when
walking?
- do you have
difficulty
breathing?
- Do you feel
pain in other
areas of the
body?
Further assessment
an X-ray should be
conducted
difficulty in
breathing or walking
shows the extent of
the bone damage
an X-ray reveals
the extent of the
fracture
There was a
dislocated shoulder,
Broken ribs bruising
on the right leg
Tachycardia is a condition where the normal heart rate exceeds the resting rate. Tachypnoea
is a condition where the patient experiences rapid breathing usually exceeding 20 breaths in a
minute. There is a link between tachycardia, tachypnoea and pain. According to past
research, patients that were under acute pain also presented a stress response that had
symptoms such as increased blood pressure, dilated pupils, increased heart rate and high
plasma cortisol levels. Patients who had a high increased rate of mortality have shown
persistent tachycardia and tachypnoea. However, since pain is subjective, the self-reported
pain scores may result in bias results.
Tachycardia and tachypnoea can also be caused by damage to the cardiovascular system.
This nursing problem present similar symptoms. Damage to the cardiovascular system can
cause the heart to function under a stressful environment. an example is patients with high

HEALTH ASSESSMENT 7
blood pressure; these patients usually have a high heart rate and tend to take deep rapid
breaths.
There are various assessments that are taken to differentiate between tachycardia and
tachypnoea that is caused by pain and symptoms caused by damage to the cardiovascular
system. Patients who have damaged the cardiovascular system usually have a high pulse rate
that is accompanied by high blood pressure. On the other hand, patients who are in pain can
usually self report the pain level. Assessing nonverbal Cues also helps to differentiate the
two problems. Patients were in pain as usually anxious and stressed. Some may cry while
others may act in aggressive behaviour; they are also easily irritable. Patients who have
cardiovascular problems tend to be fatigued and loss of consciousness is very Common.
Part C
A nursing framework is a tool that is used to generate data from a patient that will be used
for diagnosis, analysis of the patient outcome and development of a nursing intervention
(National Association of School Nurses, 2016). Through the framework nurses at able to
promote health and well-being in the community. There are two distinct assessment
frameworks that are used in nursing.; they include functional approach and biomedical
approach. The two frameworks have various advantages and disadvantages this is in relation
to the type of problems identified, contexts of the assessment and the type of data collected
(Ansell, Meyer & Thompson, 2015) (Lavoie et al., 2018).
In the biomedical approach the nurse conducts head to toe analysis of the patient. The nurse
also analyses the body systems and the vital signs such as temperature, blood pressure and
breathing rate. It is very effective in patients who have been found unconscious or semi-
conscious (Potter, Perry, Stockert & Hall, 2016). The functional approach involves analysing
specific systems in the human body for example the muscular skeleton, gastro-intestinal,

HEALTH ASSESSMENT 8
cardiovascular, psychosocial among others. functional approach framework is commonly
used by nurses. This framework is able to generate data that can be used for development of
effective nursing care plans and can easily be documented (Clark, 2015). The functional
approach framework covers the biological social psychological spiritual cultural and moral
aspect of human beings. Using this data, the nurse can make a diagnosis while considering
the interactions of various aspects . This tool can be combined with medical history and
physical examination in order to determine an accurate diagnosis (Munroe, Curtis, Murphy,
Strachan & Buckley, 2015) (Wu, Enskär, Lee & Wang, 2015).
The biomedical framework has a major disadvantage in that it is unable to identify a broad
range of some of the human responses. The framework is only able to analyse the muscular
skeleton. In addition, the data collected through the framework cannot to generate a sufficient
amount of data that can be used in the development of a holistic nursing care plan
(McDonald, Boulton & Davis, 2018).On the other hand, the functional framework is able to
identify and collect a wide range of data but it has major disadvantages. The first
disadvantage is that it consumes a lot of time. There are several assessment markers which
have to be done in order to come up with a specific diagnosis, which can be time-consuming.
Secondly a lot of irrelevant data is collected from this framework (Douglas et al., 2016)
(Malik, Moore, Patton, O'Connor & Nugent, 2018).
In conclusion, comprehensive and systematic assessment is important for future practice as a
registered nurse (Shen, 2015). This assessment is a combination of both the medical and
functional framework. Through this assessment the registered nurse is able to identify only
the relevant information. The information obtained from this assessment is enough to make a
holistic diagnosis, which can be used in the development of a care plan (Bryant‐Lukosius et
al., 2016).

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HEALTH ASSESSMENT 10
References
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assessment. British Journal of Nursing, 24(17), 886-889.
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Emergency Nursing Journal, 18(2), 83-97.

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