Initial Post: Comprehensive Health Assessment For Patient 2
Nitial Post Comprehensive Health Assessment Patient 2the Patient Pro
Nitial Post Comprehensive Health Assessment Patient 2the Patient Pro
NITIAL POST: COMPREHENSIVE HEALTH ASSESSMENT PATIENT #2 The patient profile I have been assigned is a 35-year-old white male with a history of morbid obesity with disabilities in a rural setting. This is a new patient whom I am assuming I have never met before. The first step is to build a relationship with the patient, this fosters trust between the nurse and patient. “A primary objective is to discover the details about a patient’s concern, explore expectations for the encounter, and display genuine interest, curiosity, and partnership. Identifying underlying worries, believing them, and trying to address them optimizes your ability to be of help” (Ball, J. W., et al. 2019).
A thorough health history is important as it lays the groundwork to not only build a relationship, but to efficiently diagnose a health issue or illness, and treat these health issues and illnesses. Communication with this age group needs to include non-medical jargon so the patient will understand the information presented. Medical jargon can be used but needs to be followed up with what the medical term means.
Open-ended communication is important to use, this gives the patient the ability to “fill in the blanks” with pertinent information. For example, asking the patient why they came to see you today, what health concerns they want to talk about, and keeping the conversation going by asking if there is anything else they would like to talk about. This can be added numerous times during the assessment to keep the patient talking about issues they may have. Information needs to complete a health assessment can include, past medical history, family medical history, social history, present medications, lifestyle considerations like alcohol, drug use, and smoking history. A head-to-toe assessment also needs to be completed to determine if there are any other issues needed to address.
This patient would need education regarding lifestyle changes needed related to obesity. A referral to a dietary consultant may be needed if the patient is ready to make changes to their diet. Patients who reside in rural areas have less access to nutritious foods due to distance needed to get to a store where they can buy these foods. Many rural areas have quick marts where people can get fast food, not necessarily nutritious foods. Obesity can cause many other health risks including hypertension, diabetes, joint issues, difficulty breathing, sleep apnea, skin issues like yeast infections, wounds, and stroke.
Obese patients can also have trouble with activities of daily living (ADLs) as the inability to care for themselves is common due to decreased energy and inability to complete personal cares. This patient is noted to have disabilities; this can be related to joint issues and inability to ambulate, bend, reach, and general muscular and joint problems. In relation to a risk assessment, I would include preventative care such as personal history and laboratory screening tests to rule out diabetes, prostate cancer, hypercholesterolemia, infection, and a comprehensive metabolic panel to determine if the patient had any blood-related abnormalities and to assess kidney or liver function. I would also evaluate issues related to alcohol, tobacco, or drug use, as these can lead to disease.
In my communication with the patient regarding these issues, I would be sure to tell him I ask all my patients these questions. Sullivan (2019) states, “Approaching these matters in a nonjudgmental, professional, matter-of-fact manner should enhance patient disclosure of sensitive information.”
Questions I would include in my health assessment are:
- How are you feeling today?
- What would you like for us to do today?
- What do you think is causing your symptoms?
- What are your coping mechanisms when you feel sad, scared, or angry?
- Do you have people in your life whom you can talk to?
I believe it is important to assess not only a patient’s physical well-being but also their mental and emotional health, ensuring they feel heard, involved, and satisfied with their care, which can greatly influence health outcomes.
Paper For Above instruction
Effective comprehensive health assessments are fundamental in establishing a solid nurse-patient relationship, especially for patients with complex health backgrounds such as morbid obesity and disabilities in rural settings. The approach starts with building trust and understanding through open communication, which encourages patients to share vital information about their health concerns, life circumstances, and expectations.
Developing rapport is central to gathering a complete health history, which includes medical, family, behavioral, and social factors. As Ball et al. (2019) emphasize, discovering underlying worries and addressing them through genuine interest and partnership enhances patient engagement. Using non-technical language and open-ended questions allows patients to articulate their concerns more freely and provides richer information to guide diagnosis and treatment plans.
In the context of a 35-year-old male patient with morbid obesity residing in a rural area, a detailed history becomes even more critical due to potential barriers such as limited access to nutritious foods and healthcare resources. Lifestyle factors such as diet, physical activity, substance use, and social support are integral to understanding and managing obesity-related health risks, which include hypertension, diabetes mellitus, joint problems, sleep apnea, skin infections, and increased stroke risk.
Addressing obesity involves multidisciplinary interventions, including dietary counseling, physical activity promotion, and possibly behavioral therapy. Considering the patient’s disabilities, assessments should also focus on functional abilities and assistive devices if necessary. Education tailored to the patient's context—especially awareness of how rural living may limit healthy food options—can empower them to make sustainable lifestyle changes.
Screening tests such as fasting blood glucose, lipid profiles, liver and kidney function tests, and prostate screening are essential to identify metabolic derangements and early signs of chronic diseases. These assessments help formulate personalized prevention and management strategies. Additionally, screening for substance use and mental health concerns provides a comprehensive picture of the patient’s overall health.
Effective communication throughout the assessment process involves nonjudgmental questioning about sensitive issues such as alcohol, tobacco, and drug use. Sullivan (2019) underscores the importance of approaching such topics professionally and compassionately to promote honesty and openness.
Furthermore, evaluating the patient's mental health, social support systems, and coping mechanisms is crucial. Questions regarding emotional well-being and social connectedness can reveal areas needing intervention beyond physical health, leading to more holistic care.
In conclusion, a thorough and empathetic health assessment tailored to the unique needs of a rural patient with obesity and disabilities enables healthcare providers to develop targeted intervention strategies. Combining clinical screening with patient-centered communication ensures an effective approach to managing complex health conditions and promoting positive health outcomes.
References
- Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). Elsevier.
- Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis.
- MediLexicon International. (n.d.). Morbid obesity: Symptoms, treatment, and outlook. Medical News Today.
- Center for Disease Control and Prevention (CDC). (2020). Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html
- World Health Organization (WHO). (2021). Obesity and overweight. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
- Batsis, J. A., & Zagaria, A. B. (2018). Addressing obesity in rural America: Challenges and opportunities. The Journal of the American Board of Family Medicine, 31(2), 294-297.
- Rothman, R. L., et al. (2019). Patient-centered health assessment strategies: Improving health outcomes in rural populations. Journal of Rural Health, 35(3), 302-310.
- Finkelstein, E. A., et al. (2016). The costs of obesity: The role of preventive strategies. Health Affairs, 35(2), 227-231.
- Agurs-Cizcko, A., et al. (2016). Implementing lifestyle interventions for obesity management in underserved rural populations. Journal of Community Health, 41(1), 53-63.
- Hales, C. M., et al. (2020). Trends in obesity and predictors among adults in the United States. Journal of the American Medical Association, 324(17), 1748-1758.