Health Assessment Case Study: Caring for the Nguyens

Answer

Health Assessment Case Study: Caring for the Nguyens

Health assessment is a vital element in nursing process.  Assessment skills play significant role in determining the health problems of the patient and the ability to design care plan and nursing interventions. According to Jensen (2018), the higher the level of assessment skills, the greater the ability of a care provider to make accurate judgements and nursing diagnosis. This essay, therefore, based on the case study provided, describes the types of assessment and data that have been provided by the client and the significance of such information in providing follow-up-care.

The type of assessment that is being performed at this clinic visit is comprehensive assessment. A compressive health assessment encompasses an insight into a patient’s status through observation, measurement of vital signs, as well as self-reported symptoms. It also includes the general history of both of the patient and their family members and a complete physical examination (American Nurses Association, 2015). In this clinic visit, it is clearly demonstrated that the care providers enquires about the medical history of the patient his relatives. The nurse then goes ahead to perform complete physical examination that includes measurement of vital signs and head to toe assessment, major steps of a comprehensive assessment.

The types of data that have been gathered so far are both subjective and objective. Basically, in a comprehensive assessment, there are two major types of data, which are subjective or objective. Subjective data is information provided by the patient. It includes chief complainant, past medical history of the patient, social life of the patient and the medical history of the family members (Jensen, 2018).  Therefore, an example of subjective data, in this scenario, include history of the patient and those of the family members such as diabetes and high blood pressure. On the other hand, objective data is the information gained by the care provider through assessment, observation, and diagnostic tests. In this case, the results of complete physical exam are examples of objective data. They include results of head to toe examination or laboratory.

Verification of data by the care provider is an important step in ensuring accurate diagnosis, hence he/she must confirm if the information fed on the intake sheet is accurate (Wentworth et al., 2019). One of the ways of verifying such information is picking and asking the patient same questions in the intake sheet. As long as the patient provided or fed in the correct information, the response should be similar as the ones in intake sheet. In its simple understanding, I would ask the patient the same questions as the ones in the intake sheet and compare the responses. When they are similar, then the information is correct; however, when the responses are different then I will conclude that the information fed are wrong.

Based on the information provided by Mr. Nguyen, the most important follow-up assessment is routine check of blood sugar level. According to the information provided by Mr. Nguyen, almost everyone from his father’s side has diabetes, a factor that suggest that the disease runs in the family. It is important to note that diabetes is hereditary although the genes responsible for the disease are not yet known or well researched. It is in this context that Mr. Nguyen is likely to suffer from diabetes, hence should be checked regularly for proper care.