DATE: 02/11/12

HEALTH ASSESSMENT

[Type the document subtitle] NAME: Fazilla Adrien | Group 16 |TUTOR: Sis. Francis

CONTENTS TOPIC PAGE

COMPREHENSIVE HEALTH ASSESSMENT

Mrs. X is an Antiguan living in Bolans. She is 60 years old and she is a known CVA, diabetic and hypertension patient.
Subjective Data

Demographic Data: Name: Mrs. X Date of Birth: 17th March, 1952. Address: Bolans Village Marital Status: Married Nationality: Antiguan Occupation: Unemployed Sex: Female. Next of Kin: Husband Address: Bolans Village Tel. No: 789-5540 Religion: Catholic Source of information: Secondary source - Husband Chief Complain: I have severe pain in my chest and back which started this morning.

Current History Patient X came to the emergency room accompanied by her husband. Mr. Y stated that he had left for five minutes to purchase goods at the nearby shop. When he returned home, he saw his wife lying on the living room floor with her hands on her chest crying. He stated he ask her what was wrong and she said; my chest is hurting really bad. He stated as he continues to speak to her, he notice that her speech was not very clear and that he could not understand. Her mouth twisted to the left of her face making it hard to understand. He also stated that when he assisted his wife up, he notice that his wife could not move her left hand and her left foot and complains of headache and dizziness.

Past Medical History She has a history of Diabetes and hypertension. In 2009 she was hospitalize to treat hyperglycemia. She is presently on medication to treat her condition. She has no past or present allergies to medication. Family History He stated that her deceased mother was a diabetic. Her 73 years old brother who is a diabetic and hypertensive patient is completely paralyzed, as a result of two strokes attack.

Current Health Status He maintains her health by eating healthy, doing her daily range of motion exercises (while in hospital), ambulating with assistance and taking her medication such as adalat, crestor, insulin, heparin and ciprofloxacin.

Psychosocial History She lives with her husband. She is a retired school teacher who survives in her pension and that of her husband. She receives financial assistance from her daughter who lives in the U. she was a past member of the Catholic Senior Choir. She has many friends, family and neighbors who love and support her. Neurological Patient is conscious alert and oriented to person, place and time. Speech is a bit slow but understandable. He responds adequately to command. He does not respond to tactile stimuli on the left side of his body. He made no complain of headache or dizziness. Respiratory System Patient breathing is spontaneous on room air without aided by oxygen therapy. No respiratory distress noted. No cold, productive cough or sputum present. No sign of upper respiratory tract infection noted.

Gastrointestinal System Abdomen round soft and non-distended. No scar or rashes noted. Bowel sound heard in all four quadrants when auscultated. No mass, lumps or tenderness felt when palpated.

Head-To-Toe Assessment.

Mental Status Patient is conscious, alert and oriented to person, place and time. Speech is a bit slurred but understandable. Answers question appropriately when asked. Respond to stimuli only in the left side of the body. Hair Hair is clean and evenly distributed. Scalp is clean, free from leision and movable when palpated. No swelling, bruises or trauma of the head and scalp noted. Outline of the cranium was visible. Drooling noted on the left side of face. Cranial Nerve (C7) was noted after assessment was done. Temporal artery was soft and none tendered when palpated. No brut heard when auscultated. Tempomandibular joints were assessed; patient could not move the left jaw, Impairment noted on left side of face. Frontal and maxillary muscles were palpated, no lump or tender noted. Eyes Eyes are symmetrical to each other. Eye brow and eye lashes are evenly distributed, conjunctiva moist and panic, no discharge noted. No discoloration, redness or swelling noted in Cornea and Iris, no eye infection noted, pupil respond. Papillary reflex were normal. Red reflex present peripheral vision was assessed and findings were normal, cranial nerves 3, 4 & 5 vision was not impaired and client does not wear glasses. Patient could not move eye to the six cardinal point of gaze. Assessment of the eyes was done using the Snellen chart. The client vision was 20/30 without glasses.

Ear Ear is symmetrical to each other, no discharge or swelling noted. No swelling, tenderness of the Auricle and Tragus noted when palpated. Cranial nerve 8 was assessed using the Rinnes, Weber and Whisper test and she hears well in both ears. Nose Her nose was symetrical. Septum slightly deviated to the left midline, no nasal obstruction or nosebleed noted. Both nostrils were patent and she had no problem with swelling (CI). Gastrointestinal Mouth is twisted to the left, oral mucosa were moist and pink. Uvula was in the midline as the patient said ahh! Teeth and gums clean and intact upon palpation, her gag reflex intact. Cranial nerves (9 & 10) had no problem swallowing. Cardiovascular and Integumentary Patients skin was clean and warm to touch, no bruises, swelling or redness was presented. Skin colour is even throughout body. Capillary refill brisk in return. Strong pulse felt when palpated, pulse was strong and bonding when auscultated. Genitourinary System Patient had no lumps, bruises or pain in pelvic cavity.

Musculoskeletal System.

Patient experience weakness in her left upper and lower extremities (muscle joints) with swelling noted. She could not perform range of motion to the left upper and lower extremities. No abnormalities were seen between the toes.

Review of System 1. 2. 3. 4. 5. 6. Do you have any fainting spells, headache or dizziness? Do you have any blurred vision? Are you suffering from any memory loss? Do you have any difficulties speaking? Do you have any problems in reading and writing? Have you had any past or present head injury?

Respiratory System 1. 2. 3. 4. Do you have difficulty breathing? Does it get worst when laying down or sitting? What was the onset of the chest pain? Was it sudden or gradual? Does your breathing get worst when along activities?

Musculoskeletal System 1. Do you have any pain in the joint when moving extremities and how strong is the pain? 2. Do you feel any numbness or cool in your extremities? 3. Can you walk and move your extremities? 4. Do you have any stiffness in the neck? Can you move the neck. Gastrointestinal System

1. Do you have any abdominal pain? 2. Do you feel nauseated, vomiting or diarrhea. 3. How often do you void and defecate?

Genitourinary 1. Do you feel pain voiding and defecating? 2. How often do you void? Cardiovascular System 1. Is this your first stroke attack? 2. Do you suffer from any chronic diseases for e.g. Diabetes or Hypertension? 3. Was the onset sudden or gradual? How long did they last? 4. Is there any history of stroke in your family? 5. Does the pain feel sharp, dull or crushing? Was the onset sudden or gradual? 6. Do you smoke cigarettes? 7. Do you exercise and what kind of exercise you perform? 8. Are you under serious stress and how you handle it? 9. Are you taking any prescribed or Over-the-Counter medication? If yes (what is the name of the drug/s dosage and time taken). 10. Are you on any contraceptives and what type? 11. Do you have allergies to any type of drugs? 12. What were you doing when the pain first occurred for e.g. sleeping, sweeping etc?