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Hi, need to submit a 2000 words paper on the topic Comprehensive Health Assessment and Documentation.
Hi, need to submit a 2000 words paper on the topic Comprehensive Health Assessment and Documentation. The comprehensive health assessment shall be conducted and later presented in this paper for the patient’s Primary Health Care provider. Such comprehensive history shall later be used to adapt a plan of care for the client and to assess the comprehensive assessment skills of this student.
The patient is lying in bed. She is in a side-lying position with her knees bent. She is also clutching her lower abdomen while in this position. She is not relaxed because of the pain she is experiencing. All her movements seem to be voluntary and under her control.
The patient’s clothes are clean and properly fastened. They are appropriate for her age and social group. She is well-groomed. and she has clean nails, hands, teeth, skin, and hair. Both sides of her body appear to be properly groomed and well-cared for.
She grimaces often from the pain she is experiencing. She also looks worried and anxious about her upcoming surgery. She often guards her expression when her family members are around. The changes in her expression match the topics under discussion. She manifests expressions of anxiety when the attending physician told her that she had acute appendicitis, and again when she was told that she had to have an appendectomy.
The patient’s affect varies accordingly based on the topics under discussion. They are also appropriate based on the topic being discussed. She is open and approachable and reacts appropriately to other people and to the surroundings. She does not appear to see or hear things that are not there.
She is relatively silent, but she spontaneously responds to questions being asked of her. The speed of her speech varies. She speaks fast when she is in pain and slows down when the pain subsides. She speaks softly and is sometimes inarticulate when she is experiencing extreme pain. When the pain subsides, she speaks clearly and distinctly. The flow, rate, and melody of her speech seem to be normal.