Shadow Health physical comprehensive assessment

Final Project

The Final Project (6-8 page paper) synthesizes the previous weeks’ study of advanced physical assessment by conducting a comprehensive assessment in Shadow Health. The final project synthesis is focused upon designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan. Assessment of competency is based on the Comprehensive Patient Interview, Physical Examination and Individualized Plan of Care incorporating Healthy People 2020 and evidence-based interventions and patient-centered goals.

You will use one comprehensive digital clinical experience health history and physical assessment for this assignment: Comprehensive Assessment. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. The use of Headers in your paper is strongly encouraged.

Submission Parameters:

For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 6-8 pages, which does not include the cover page and reference page(s).

Introduction (including purpose statement)
Subjective Findings Synthesis
Objective Findings Synthesis
Plan of Care
1. Apply one nursing theory in planning care for this patient
2. Incorporate Healthy People 2020 Objectives into the plan of care prioritized to meet the health needs of the patient
3. Document evidence to support clinical reasoning for selected evidence-based plan of care
4. Plan of care is individualized to findings, life-span stage of development with culturally specific considerations, and patient-centered.
Conclusion
References (use primary and/or reliable electronic sources)

In regards to APA format, please use the following as a guide:

Include a cover page and running head (this is not part of the 6-8 pages limit)
Include transitions in your paper (i.e. headings or subheadings)
Use in-text references throughout the paper
Use double space, 12 point Times New Roman font
Apply appropriate spelling, grammar, and organization
Include a reference list (this is not part of the 6-8 pages limit)
Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)

The Final Project documentation is due in Week Seven. Please see the Final Project below to help you complete the assignment.

Final Project Rubric

Competency	20	18	16	0	Earned/ Possible Points
The history, assessment and key findings are synthesized	Documentation clearly shows student has completed a comprehensive assessment with a written synthesis of key findings.	Documentation supports the student has completed the comprehensive assessment with key findings.	Documentation supports the student has completed the assessment without documentation of key findings.	Documentation supports the student attempted to complete the comprehensive assessment without identification of key findings. The comprehensive health history is briefly documented and lacks depth and specificity.	/20
	20	18	16	0
Documented Prioritized Physical Examination Findings	Documentation clearly shows student has completed the physical examination with findings prioritized.	Documentation supports the student has completed the physical examination with findings.	Documentation supports student completed some of the physical examination. Documentation is accurate but lacks depth.	No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability.	/20
	20	18	16	0
Documented Evidence to Support Clinical Reasoning with External Course Resources	Discourse clearly shows the student has studied the topic and has given thought in developing the final plan of care with one nursing theory applied and integration of Healthy People 2020.	Discourse supports the student has studied the topic and has given thought in developing the final plan of care. Lacks integration of either one applied nursing theory or integration of Healthy People 2020.	Discourse upports student studied some of the topic, however, lacks detail and depth in developing the final plan of care. Lacks integration of either one applied nursing theory or integration of Healthy People 2020.	No evidence that that student has read or studied the topic. Discourse lacks depth. May be presented in a rambling manner. Content is inaccurate &/or is unclear. No use of one applied nursing theory or integration of Healthy People 2020.	/20
	20	18	16	0
Individualized and Prioritized Plan of Care is Based Upon Clinical Findings	Accurately presents an individualized plan of care based upon clinical findings.	Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted.	Presents a plan of care that is not individualized based upon the clinical findings.	A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings.	/20
	5	4	3	0
Developmentally and Culturally Specific	Accurately documents a development-ally and culturally specific assessment and plan of care for the selected patient.	Documents a development-ally and culturally specific assessment and plan of care.	Presents a development-ally and culturally specific assessment or plan of care and one or both are not based upon the selected patient.	A development-ally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings.	/5
	5	4	3	0
Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice	Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the comprehensive physical assessment.	Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation.	Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the comprehensive physical assessment or inaccuracies are evidenced in the written assessment.	Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the physical assessment.	/5
	10	9	8	0
Grammar, Spelling, and Punctuation APA Format	APA Format, grammar, punctuation and spelling is accurate with errors.	APA Format, grammar, punctuation and spelling is accurate with less than two types of errors.	APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors.	APA Format, grammar, punctuation and spelling is accurate with more than five types of errors.	/10
COMMENTS:				TOTAL:	/100

Week 7 Final Project

Introduction

The key purpose of the Shadow Health physical comprehensive assessment is to allow learners to examine and demonstrate their physical assessment skills and the clinical reasoning skills acquired during the course. The selected Shadow Health virtual assessment include a 28-year-old female patient named Tina Jones. The patient presented for a pre-employment physical assessment required by the insurance at her new workplace. This paper aims to present an analysis of the acquired learning, knowledge, skills, and competency by discussing the comprehensive assessment of the patient utilizing a relevant nursing theory and applying the relevant Health People 2020 (HP2020) goals to Tina Jones. The paper will also present an evidence-based care plan that integrates the cultural needs and lifespan of Tina Jones. This means that the care plan will be patient-centered.

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Subjective Findings Synthesis

The patient reported that she had come for a pre-employment physical assessment that was needed at her new workplace. The patient reported that she was diagnosed with asthma during her childhood and diabetes when she was 24-years old. She was also diagnosed with PCOS four months ago. The current medications for the patient include metformin for diabetes, oral contraceptives for the PCOS, Fluticasone, Albuterol, Drospirenone, Acetaminophen, and Ethinyl-estradiol. She has not experienced any major side effects with the current medications. However, Tina reported that metformin was initially giving her bloating, but she uses yogurt to relieve the bloating.

According to the patient, she manages diabetes using metformin medication, regularly monitoring and testing the blood glucose levels, and lifestyle modifications that include a healthy diet that consists of a high intake of fruits and vegetables and increased exercise, and weight loss. The patient reported that the range of her blood glucose levels is 90, indicating that her blood glucose levels are within normal limits. The patient stated that her asthma is now well-controlled and the inhaler has decreased asthma exacerbations. She reported that she had her annual vision examination and was given glasses, which have helped in improving her eyesight. The oral contraceptives have stabilized her menstrual cycle. She has also limited her caffeine intake and occasionally takes alcohol. She does not abuse any drugs. Tina reports that she has had recent weight loss due to her recent lifestyle modifications.

Tina reported that her social life is great. She is in a good new relationship and regularly interacts with her friends. She is also active in her church and participates in Bible study with her church members. She currently stays with the mother but she hopes to move out and start living alone within a month. She reports that her family interactions are great and she is currently very happy, especially with her new job. The patient denied any form of stress, anxiety, sleep problems, or depression. This means that her mental health is good.

The patient denied any muscle pain or joint pain, indicating that her musculoskeletal system is well and healthy. For the neurological system, the patient denied any dizziness, lightheadedness, or numbness. She also denied having had any seizure. She also denied any increased heartbeat, palpitations, or tachycardia. The patient also denied any nausea, vomiting, abdominal pain, or diarrhea.

Objective Findings Synthesis

The vital signs are within normal limits. The spirometry readings show that the lung functioning of the patient is normal. From the assessment of the respiratory system, the chest is resonant with percussion; breathing clear; and the chest is symmetrical. The assessment of the cardiovascular system did not show any abnormality as evidenced by the absence of any heaves or lifts. Moreover, the assessment did not reveal any bruit within the carotid arteries. The heart rate for the patient is normal and there were no heart murmurs. The patient’s capillary refill was less than two seconds, showing that her blood flow is normal.

The assessment of Tina’s gastrointestinal tract system did not show any abnormality as there were no masses in the abdomen, normal bowel sounds in all quadrants, and there was no flank pain bilaterally. The liver was palpable, but the kidneys and the spleen were not palpable. Normally, kidneys and spleen are not usually palpable in adults. The assessment of the patient’s musculoskeletal system showed that the range of motion was present in all limbs. Motor skills and muscle strength were also within the normal range. The assessment of the neurological system showed that the stereognosis, graphesthesia, and rapid alternating movements for this patient were all within the normal range. However, it was noted that there was a decreased sensation after using the monofilament on the plantar. The reduced sensation indicates that the patient may be having peripheral neuropathy. Peripheral neuropathy is a common condition in people with diabetes and it is characterized by numbness, weakness, and pain due to nerve damage (Colloca et al., 2017). It is thus necessary to refer the patient for a foot examination. The assessment of the skin, hair, and nails did not show any abnormality. However, the face has acne and facial hair, and some part of the skin was darkened; these are common symptoms in PCOS.

Plan of Care

The patient has obesity as indicated by the high weight. Four months ago, the patient was diagnosed with PCOS. PCOS is a normal disorder in females and it is accompanied by symptoms such as severe acne, facial hair, irregular periods, and polycystic ovaries. Having obesity and being overweight are risk factors for PCOS (Rocha et al., 2019). Treatment and management of PCOS normally include contraceptives, lifestyle modifications that facilitate weight loss, and medications that trigger ovulation. PCOS can lead to complications such as ovarian cancer, diabetes, infertility, sleep apnea, uterine bleeding, poor mental health, and eating disorders (Rocha et al., 2019).

The patient has type 2 diabetes, which is a chronic disorder associated with a problem with the metabolism of glucose in the body (Blaslov et al., 2018). The prevalence and incidence of type 2 diabetes are very high within America and it is a major public health concern. The condition is accompanied by symptoms such as increased thirst and hunger; impaired vision; frequent urination; acanthosis nigricans; and slow wound healing. The risk factors associated with type 2 diabetes include abdominal fat, sedentary lifestyle; old age, and poor diet (Blaslov et al., 2018). Therefore, diabetes can be prevented by consuming a healthy diet and being physically active. Type 2 diabetes comes with complications like heart disease, kidney problems, foot problems, vision impairment, foot problems, and neuropathy. Evidence shows that diabetes can be managed by consuming a healthy diet, adhering to the prescribed treatments such as insulin, monitoring of the blood glucose levels daily, and being physically active (Blaslov et al., 2018).

Healthy People 2020 indicates that lifestyle modification is an effective strategy for the prevention and management of type 2 diabetes (Koh et al., 2016). Effective and close monitoring of the blood glucose levels for people with diabetes is among the key Healthy People 2020 goals. Therefore, people with diabetes are encouraged to often monitor their blood glucose levels, adopt healthy lifestyles, and adhere to the prescribed treatments and lifestyle modifications. The patient (Ms. Jones) tests her blood glucose levels regularly; has adopted the recommended lifestyle modifications; and is compliant with the prescribed medications. Ms. Jones has thus met this goal of Healthy People 2020.

The second identified goal of Healthy People 2020 is increasing the number of individuals diagnosed with diabetes and they attend the annual eye examination (Koh et al., 2016). Ms. Jones attended an eye examination where she was prescribed glasses to correct her eyesight. The patient has thus met this goal of Healthy People 2020. Additionally, increasing the number of individuals with diabetes undertaking annual foot examinations is another goal of Healthy People 2020 (Koh et al., 2016). Therefore, it is recommended that the patient attends the annual foot examination in order to meet this goal.

The BMI of the patient is approximately 29, indicating that she is overweight. Common causes of overweight and obesity include lack of physical activities and poor eating habits. Therefore, Ms. Jones needs to continue adhering to a healthy diet and being physically active in order to reduce the weight. Being overweight and obesity can lead to health complications such as diabetes, hypertension, cancer, reproductive problems, and heart disease. (Cercato & Fonseca, 2019).

For the cultural aspect, it is important to consider that the patient is an African American. Therefore, her cultural preferences should be integrated into the care plan to ensure the provision of culturally sensitive care (Jongen et al., 2018). Ms. Jones is an educated and independent young woman. It will be important to actively involve her when developing her treatment plan. She is a Christian as indicated by being an active church member and thus the spiritual aspect of Christians should be included in the care plan.

The nursing model that will be used to guide the patient’s care is Orem’s Self-Care Deficit Theory. According to this theory, people should be reliant and take charge of their health and care. This can be achieved by individuals perming activities and behaviors that promote and maintain good health such as eating the right foods, maintaining a clean environment, taking rest, having healthy interactions, and avoiding the obvious dangers and hazards (Khademian et al., 2020). Self-care also involves seeking healthcare services when necessary, being compliant with the prescribed treatments, and accepting one’s health condition, and taking the necessary steps to improve health (Khademian et al., 2020). Ms. Jones normally seeks healthcare services when necessary, has adopted the recommended lifestyle modifications, and is compliant with the treatment regimen. This indicates that she is following the Orem’s self-care theory. Moreover, Ms. Jones has accepted the diagnosis and this is the reason she is adhering to the treatment regimen and the recommended lifestyle modifications. She also attends the recommended annual examinations such as eye and gynecological annual examinations. Therefore, the patient demonstrates a positive self-care.

Conclusion

The patient who underwent a comprehensive physical assessment is a 28-year-old African American female who presented for a physical assessment required at her new workplace. She reported that she has type 2 diabetes, asthma, and was also diagnosed with PCOS. Currently, diabetes and asthma are well-controlled, and also oral contraceptives have stabilized the menstrual cycle. The only notable health concerns from the assessment include being overweight and the loss of sensation in the feet. She has made positive lifestyle modifications such as exercising and eating a healthy diet. She also adheres to the treatment regimen and closely monitors the blood glucose levels. The proposed health recommendations for the patient include that she should undergo foot assessment and A1c testing due to the noted loss of sensation on her feet.

References

Blaslov, K., Naranđa, F. S., Kruljac, I., & Renar, I. P. (2018). The treatment approach to type 2 diabetes: Past, present, and future. World journal of diabetes, 9(12), 209–219. https://doi.org/10.4239/wjd.v9.i12.209

Cercato, C., & Fonseca, F. A. (2019). Cardiovascular risk and obesity. Diabetology & metabolic syndrome, 11(1), 74.

Colloca, L., Ludman, T., Bouhassira, D., Baron, R., Dickenson, A. H., Yarnitsky, D., Freeman, R., Truini, A., Attal, N., Finnerup, N. B., Eccleston, C., Kalso, E., Bennett, D. L., Dworkin, R. H., & Raja, S. N. (2017). Neuropathic pain. Nature reviews. Disease primers, 3, 17002. https://doi.org/10.1038/nrdp.2017.2

Jongen, C., McCalman, J., & Bainbridge, R. (2018). Health workforce cultural competency interventions: a systematic scoping review. BMC health services research, 18(1), 232. https://doi.org/10.1186/s12913-018-3001-5.

Khademian, Z., Kazemi Ara, F., & Gholamzadeh, S. (2020). The Effect of Self Care Education Based on Orem’s Nursing Theory on Quality of Life and Self-Efficacy in Patients with Hypertension: A Quasi-Experimental Study. International journal of community-based nursing and midwifery, 8(2), 140–149. https://doi.org/10.30476/IJCBNM.2020.81690.0

Koh, H. K., Blakey, C. R., & Roper, A. Y. (2016). Healthy People 2020: a report card on the health of the nation. Jama, 311(24), 2475-2476.

Rocha, A. L., Oliveira, F. R., Azevedo, R. C., Silva, V. A., Peres, T. M., Candido, A. L., Gomes, K. B., & Reis, F. M. (2019). Recent advances in the understanding and management of polycystic ovary syndrome. F1000Research, 8, F1000 Faculty Rev-565. https://doi.org/10.12688/f1000research.15318.1.