Physical examination and health assessment

Physical examination and health assessment

As the school nurse working in a college health clinic, you see many opportunities to promote health. Maria is a 40-year-old Hispanic who is in her second year of nursing school. She complains of a 14-pound weight gain since starting school and is afraid of what this will do to both her appearance and health if the trend continues. After conducting her history, you learn that she is an excellent cook and she and her family love to eat foods that reflect their Hispanic heritage. She is married with two school-age children. She attends class a total of 15 hours per week, plus she must be present for 12 hours of labs and clinical. She maintains the household essentially by herself and does all the shopping, cooking, cleaning, and chauffeuring of the children. She states that she is lucky to get 6 hours of sleep per night, but that is okay with her. She lives 1 hour from campus and commutes each day. Using Healthy People 2020 (Physical examination and health assessment)

(Links to an external site.)

Links to an external site.

and your text as a guide, answer the following questions.

What additional information would you like to gather from Maria?

What are Maria’s real and potential health risks?

Why is Maria’s culture important when obtaining the health assessment?

Pick one of Maria’s health risks. What would be one reasonable short-term goal for this risk?

What nursing interventions would you incorporate into Maria’s plan of care to assist her with meeting your chosen goal? Please provide rationale for your selections.

http://Jarvis, C. (2016). Physical examination & health assessment (7 th ed.) Philadelphia, PA: Saunders.

(Physical examination and health assessment)

 
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Common Health Conditions with Implications for Women

Common Health Conditions with Implications for Women

Select a patient that you examined during the last four weeks as a Nurse Practitioner. Select a female patient with common endocrine or musculoskeletal conditions, Evaluate differential diagnoses for common endocrine or musculoskeletal conditions you chose .With this patient in mind, address the following in a SOAP Note: (Common Health Conditions with Implications for Women)

Subjective: What details did the patient provide regarding or her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up appointment with the provider, as well as a rationale for this treatment and management plan.

Reflection notes: What would you do differently in a similar patient evaluation? And how can you relate this to your class and clinical readings.

References

Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers.

Chapter 22, “Urinary Tract Infection in Women” (pp. 535–546)

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.

Review: Chapter 8, “Primary Care in Women’s Health” (pp. 431–560)

Centers for Disease Control and Prevention. (2012b). Women’s health. Retrieved from http://www.cdc.gov/women/

National Institutes of Health. (2012). Office of Research on Women’s Health (ORWH). Retrieved from http://orwh.od.nih.gov/

U.S. Department of Health and Human Services. (2012a). Womenshealth.gov. Retrieved from http://www.womenshealth.gov/

nurs_6551_wk_11_sample_soap.docx

 
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