Nursing health assessment is an important role for a patient being diagnosis and give appropriate treatment

Nursing health assessment is an important role for a patient being diagnosis and give appropriate treatment

Nursing health assessment is an important role for a patient being diagnosis and give appropriate treatment (Bellack, 1992, p.12). In my past clinical practice, only some simple assessments were conducted as it is able to reduce the affect of the problem but not solve it. After studied nursing health assessment, some more extensive and specific assessments should be done to identify patient’s health status.

Check your essay before you submit. See exactly what your professor sees.

See your AI and plagiarism results before your instructor does.Get the exact same report your professor uses. Trusted by 50,000+ students worldwide.

Get Plagiarism Report Humanize My Essay

The actual problem, strengths deviations and the risk of the health problem are explored at a detail and in-depth way. This article is going to discuss about the specific nursing health assessment for a patient suffered from abdominal pain, who was met in my past practicum placement.
Case scenario

Ms. Ma, Age 54, housewife, admitted via A&E and complained she was having abdominal pain for 5 days. Sharp pain starts at mid-abdomen and then at right lower quadrant. Level of pain increased when coughing. She had had Panadol 500mg an hour ago but pain can not relief. Nausea and vomited small amount of undigested food twice in the past few days.

No diarrhea. She feels tired but can not sleep because of the sharp pain. Her vital signs are: pulse 98, blood pressure 148/85 mmHg, temperature 39.2oC. Her skin is warm and dry. Rebound pain occurred at the right lower quadrant of abdomen. She has hypertension and need to take medicine 2 times per day.

Ms. Ma was diagnosed with acute appendicitis. Keep NPO and IV 500ml normal saline is established. Blood test, abdominal X-ray and ultrasound abdomen are planned.
Assessment of abdomen

In the past clinical practice, I only give analgesics by doctor’s order and the patient may sometimes relief pain after medication. However, abdominal assessment skills are necessary to identify Ms. Ma‘s condition for getting at the root and having a better outcome.

There are five important steps for evaluating abdomen: take health history, inspection, auscultation, percussion and palpation. These assessment skills will be discussed one by one in the following paragraphs.
Health history and lifestyle health practices

First, find out the patient’s chief complaint, record the details and observe Ms. Ma‘s general appearance.

Then, assess the abdomen pain by COLDSPA— character, onset, location, duration, severity, pattern and associated factors. It is the most accurate measurement to identify whether it is parietal peritoneal pain, visceral pain or referred pain (Judy, 2008).

After that, collect individual and family past and current health status. Ask if there was any injuries or trauma may cause the pain, any eating disorder, any abdominal surgery was done before, any food allergy, history of suffering inflammatory bowel disease, family history of cancer and chronic disease, etc. Also, collect Ms. Ma‘s lifestyle and health practices.

Ask her if smoke, drink or not, her eating habit, bowel pattern and movement, the amount, colour and texture of stool, any change in appetite, weight and abdominal girth recently and her stress level (Medical Education, 1998).

Past history and current lifestyle health practices are the useful information to identify the risk factors of the problem.

After collecting all background information, the physical examination should be proceed. Physical examination is using senses to collect objective data. It is used to identify the actual and potential health problems, discover patient’s abnormalities and diagnosis the problem (Nursing 2010 Magazine, 2010).

For physical examination of abdomen, Ms. Ma needs to empty her bladder first in order to avoid the bladder irritation then, place Ms. Ma in a supine position. The hands should be at aside and knees slightly bent. Tell her keep relax of the abdominal muscles. The assessment should be started in the right lower quadrant of abdomen and then proceeding in a clockwise direction.

Also, the examination should go forward in the order of inspection, auscultation, palpation and finally percussion for avoid affecting the quality of bowel sound and increase peristalsis (Bellack, 1992).