Running head: NURSING: HEALTH ASSESSMENT PLAN OF CARE 1

Nursing: Health Assessment Plan of Care

Delaware Technical Community College

NUR 320 Health Assessment

Veronica Franco

April 11, 2017

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Nursing: Health Assessment Plan of Care

Nursing Health Assessment is an essential component of the nursing practice. It provides

us with the ability to evaluate the patient using a holistic approach. The holistic assessment

incorporates the physiological, psychological, sociological, developmental, spiritual, and

cultural needs of the patient (Wallace, 2013, pg.1). It is essential to consider each and every

component of the assessment in order to fully comprehend the individuality of the patient. This

paper will incorporate the health assessment performed to a 19-year-old Caucasian female in

developing an appropriate care plan.

The first problem identified during the assessment process was pain related to lifting,

pushing, or carrying heavy objects as evidenced by a numerical rating scale report of 5 on the left

top middle wrist, tension during palpation, and decreased ability to perform ADLs. Two years

ago she traveled to Germany and upon arrival back to the United States, she had to carry her

heavy luggage. Lifting her bags caused her to develop pain. The patient further explained that it

is hard to perform exercises such as weight lifting, pushups, and flexing the wrist. The identified

outcome for this patient is that she will verbalize a decrease amount of pain of less than 3 by the

end of the week. Pain is a public health issue that affects approximately 100 million Americans

and costs between 560 and 635 billion dollars yearly (Helmick, 2014). It is important to provide

solutions to aid in relieving pain. One important intervention is encouraging the patient to

perform activities when she is fully rested in order to decrease discomfort. In addition, it is

essential to decrease causative factors of pain such as heavy lifting, stress, and fatigue.

Unfortunately, pain can sometimes be undertreated and can impact the individuals quality of life

(Helmick, 2014). Educating the patient on appropriate non-pharmacological interventions such

as massage, heat or cold compressions, and distracting activities can aid in reducing pain. It is
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important to refer the patient to a physician if the pain becomes more severe. In order to evaluate

the effectiveness of pain control, the patient was asked to follow the established interventions

and report back within a week. The patient verbalized a decrease amount of pain of three, after

one week.

The second problem that was identified for the patient is having a disturbed body image

related to inflammatory lesions of acne as evidenced by erythematous pimples on cheeks and

forehead, verbalization of anxiety, and low self-esteem. Currently the patient is experiencing an

increased amount of acne on her face and has expressed feelings of decreased self-esteem. The

goal established for this patient is that she will verbalize an increased self-confidence and explain

the appropriate hygiene and treatment for acne by week one. The priorities in this case are

analyzing her current skin care routine, diet, and stressors (Pearson Higher Education, n.d.). She

explained that she likes to frequent fast food restaurants because they are close to home and has

attempted to make changes in her diet by incorporating home made foods such as boiled chicken

and salads. It is imperative to explain to her that diet and stressors can also influence the

development of acne. The US Department of Health and Human Services and US Department of

Agriculture explains that consuming a nutrient rich diet with the appropriate number of calories,

can aid in maintaining a healthy weight and reduce the prevalence of chronic illness (2015).

Cleansing the face twice a day and moisturize can help control the amount of sebum (American

Academy of Dermatology, 2017). Furthermore, incorporating over the counter skin care products

can help decrease the level of acne present in the skin. The American Academy of Dermatology

explains that using products with benzoyl peroxide and salicylic acid, could lead to positive

improvements within 4 to 8 weeks (2017). For evaluation, the patient was able to demonstrate

appropriate hygiene and treatment and verbalized an increased in self-confidence after week one.
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If the acne becomes severe, it is essential to refer the patient to a dermatologist. The

dermatologist can prescribe medications that can be more effective in the treatment of acne.

The final problem addressed was anxiety related to financial stress as evidenced by

verbalization of increased stress, decreased sleep, and concentration. The patient explained that

her income doesnt meet her needs. She is required to pay for her college tuition and has to rely

on her mother-in-law for financial support. The expected outcome for this problem is that the

client will incorporate relaxation techniques at least 3 times per week. According to the National

Institute of Mental Health, anxiety can intervene with the patients ability to effectively

accomplish things such as work, school, and relationships (2016). The priority for the patient is

to educate her on relaxation techniques such as breathing exercises, meditation, taking warm

baths, or massage. Incorporating stress-reducing techniques, can aid in calming the patient

(National Institute of Mental Health, 2016). In addition, determining what her budget is and

prioritizing what things are essential for her needs, is necessary (Weigel, n.d.). It is important to

involve her family in finding the best ways to cope with the situation. Determining what other

financial support she can receive, is another intervention that was determined (Weigel, n.d.). For

evaluation, the patient was able to incorporate relaxation techniques at least 3 times per week.

Finally, there are many community resources available that can provide financial aid. Some of

the resources can include applying for community resources such as food stamps and Medicaid.

Health assessment is a tool that can help determine the needs of the patient. It is essential

to create plans of care that are specific to the patients situation and can be successfully

accomplished with the proper education and resources.

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References

American Academy of Dermatology. (2017). Acne. Retrieved from

https://www.aad.org/public/diseases/acne-and-rosacea/acne#treatment

Helmick, C. (2014). Adding chronic pain objectives to healthy people 2020. Retrieved from

https://iprcc.nih.gov/meetings/2014/092414%20Presentations/2Helmick_HP2020.pdf

National Institute of Mental Health (2016). Anxiety disorders. Retrieved from

https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

Pearson Higher Education. (n.d.) Nursing care plan the adolescent with acne. Retrieved from

http://wps.prenhall.com/wps/media/objects/354/362846/Child%20-%20Acne.pdf

US Department of Health and Human Services and US Department of Agriculture. (2015). 2015-

2020 Dietary guidelines for americans. Retrieved from

https://www.healthypeople.gov/2020/tools-resources/evidence-based-

resource/2015%E2%80%932020-dietary-guidelines-for-americans

Wallace, S (2013). The importance of holistic Assessment- a nursing student perspective.

Retrieved from

https://www.researchgate.net/publication/275893594_The_importance_of_holistic_assess

ment_-_A_nursing_student_perspective

Weigel, R. (n.d.). Coping with Financial Stress. Retrieved from

http://www.uwyo.edu/uwe/sustainable-ag/drought/drought-stress-coping-with-financial-

stress.html