Case study physical assessment

Physical examination and health assessment Affiliation In any diagnosis or treatment decisions, the health professionals rely on the data collected and the information gathered through the assessment process. It is therefore important for the nurses or other health professional collecting the data or inspecting the patient to ensure that they have made a thorough assessment of the patient’s condition before presenting a report to the doctors for assessment. This paper uses the case study of J. P a 15-year old African-American adolescent who has been diagnosed with Sickle-cell disease. The case study offers the different forms of data and assessment procedures that a health assessment should take, which should follow the elements that “ form the database of the assessment of the person’s health” as provided in chapter 1 in Jarvis (2012, pg. 2).
There are two types of data collected, the subjective data and the objective data. The subjective data is collected through collecting and analyzing what the patient is saying while conducting the examination. On the other hand objective data is the data collected by the medical examiner through inspecting, percussing, palpating, and auscultating while performing the medical examination (Jarvis, 2012). While it is crucial for an objective assessment to be conducted, the subjective data that allows one to understand the patient better is essential in understanding the patient better and come up with the best diagnosis as well as the treatment process for the patient.
One of the main assessments that need to be analyzed is the cultural considerations of the patient. In the case study, the patient is an African American adolescent that has been exposed to different conditions that are not favorable to the development and well-being of the child. JP lives with the grandmother and was raised in a violent family where the mother and father were in constant altercations. The mother died of Heroin overdose and has also lost his father who died five years ago. These factors affect the normal up-bringing of JP and with the sickle-cell disease that he is currently enduring the cultural background is one of the main factors that will affect his condition. According to Jarvis (2012) the musculoskeletal function is affected by the cultural background and the life of the patient. According to Jarvis chapter 15, the musculoskeletal system “ provides locomotion, an upright posture, and protection for the body” (Jarvis, 2012, pg. 177). In this regard looking at JP is African-American the muscles are deemed to be different and hence the dynamics of the treatments and also diagnostics need to be assessed.
Sickle cell disease is a group of disorders that generally affect the hemoglobin thereby making it to form abnormal hemoglobin molecules. When collecting the objective data of the disease instead of focusing on historical data and other descriptive measures as given by the patient. While inspecting the patient the nurse should conduct a thorough screening in which they examine the different symptoms that the patient may have (Camera and Mosby, 2009). Inspecting the eyes and assessing whether there are signs of jaundice is one of the main characteristic that should be inspected. The temperature of the patient should also be examined to determine whether the patient may experience sepsis and also cases of severe dehydration (Jarvis, 2012). When conducting palpation the nurse should assess the weakness and the level of fatigue that the patient shows.
Through the use of the hands and one can be able to examine the joints and muscle strength of the patient. There is also the use of percussion to measure the strength of the joints and the muscles of the patient (Jarvis, 2012). Auscultation is also essential in order to measure the ability of the patient breathing and also oxygen saturation to measure for steady state and lung consolidation. By using of the subjective and objective methods of collecting data health assessment can help in the diagnosis and treatment of a patient.
References
Camera, I. M., Loretz, L., & Mosby, Inc. (2009). Physical examination & health assessment. St. Louis: Mosby Elsevier.
Jarvis, C. (2012). Physical examination & health assessment. St. Louis, MO: Saunders/Elsevier.