OAP Final Health Assessment Fallon Jefferson O: General Health Survey: Appears younger than stated age (31

years). Well developed, wellnourished woman, neatly dressed and well groomed. Orient to person, place, and time; appropriate effect. Speech clear and responds appropriately. No acute distress at this time. Moves all extremities well, gait balanced and coordinated. Heights 59; weight 165 lb. Vital signs: Temperature, 98.4 degrees Fahrenheit; pulse, 58; respirations, 13 per minute; BP, 110/84. Integumentary: Skin even in color, warm, dry, positive turgor, no suspicious lesions. White scar from broken jaw on anterior mandible. Hair clean, coarse, blond, evenly distributed. Nails pink, 2 second capillary refill, no clubbing. Head/Face/Neck: Normocephalic, erect, midline. Scalp mobile, no lesion, tenderness, or masses. Facial features symmetrical. Thyroid not palpable. No palpable lymph nodes. Eyes: Snellen: R:20/20; L: 20/20; Both: 20/20. Difficulty noted with distant vision without prescription contacts. EOMs intact, no nystagmus. Corneal light reflex symmetrical bilaterally. No drifting. Eyes clear and bright; positive blink reflex; no lid lag, ectropion/entropion, or lesions noted on lids; cornea, iris intact; anterior chamber clear. Sclera white, conjunctivae clear and glossy. Lacrimal glands and ducts nontender. PERRLA direct and consensual. Positive constriction and convergence. Red reflex present bilaterally, disc flat with sharp margins, vessels present without crossing defects, retina even in color without hemorrhages or exudates, macula even in color. Ears/Nose/Throat: Skin of external ear intact with no lesions, masses, or discharge. Tragus, mastoid, and helix nontender. Positive right ear whisper test. Weber test: left side unilateral hearing deficit, high tone frequency loss. Rinne: ac > bc bilaterally. External canal clear without redness, swelling, lesions, or discharge. Tympanic membranes intact, pearly grey with light reflex and landmarks visible. Frontal and maxillary sinuses nontender. Nares patent; patient recognizes familiar odor. Nasal mucosa pink, septum intact with no deviation. Mouth: Lips, oral mucosa, gingivae pink without lesions. Teeth all present and clear; no obvious caries. Pharynx pink, tonsils +1, palate intact. Symmetrical rise of uvula, positive gag and swallow reflex. Tongue smooth, pink, symmetrical, no lesions, taste intact, full ROM. Glands nonpalpable. Respiratory: respiration unlabored, trachea midline. AP< transverse diameter. Chest expansion is symmetrical; no tenderness, scar, masses, or lesions. Equal excursion, no lag, equal tactile fremitus. Resonant percussion sound over lung fields. Lungs clear no adventitious breath sounds. Cardiovascular: PMI 1 cm at fifth intercostal space at midclavicular line. Heart rate regular; S1, S2; no S3, S4, murmurs, gallop, or thrills present. Pulse +2, no bruits or thrills, no varicose veins. JVP at 45-degree angle. Abdomen: Abdomen flat, no masses or pulsations. Bowel sounds present, no vascular sounds hear. Tympany in all four quadrants. Liver 8 cm at right midclavicular line. Abdomen soft, no hepatomegaly ,splenomegaly, masses, or tenderness. Negative abdominal reflexes. Kidneys nonpalpable. Aorta 2 cm. No CVA tenderness. Musculoskeletal: No scoliosis, kyphosis, or lordosis. Joints and muscles symmetrical, nontender; no deformities. Right side dominant, arm and leg lengths and

circumferences equal, equal hand grasp. Muscles well developed, +5 muscle strength. Full ROM in upper and lower extremities; no crepitus. Neurologic: Cooperative; responds appropriately. CNs I through XII intact. Gait steady and coordinated; no pronator drift; negative Romberg; able to heel-and-toe walk and do deep bends without difficulty. Point to point localization intact. Superficial and deep sensations intact. +2 DTR, +plantar flexion. A: Disturbed sensory perception: auditory, related to altered sensory perception and transmission as evidenced by intermittent tinnitus in left ear. Acute pain related to physical trauma of the neck as evidenced by muscle spasms and stiff neck. P: 1. Speak clearly in lower voice tones if possible. Do not over enunciate or shout at the client. In many kinds of hearing loss, clients lose the ability to hear higher-pitched tones but can still hear lower-pitched tones. Over-enunciating makes it difficult to read lips. Shouting makes the words less clear and may be painful (Ackley & Ladwig, 2011). 2. Keep background noise to a minimum. Turn off television and radio when communicating with the client. If in a noisy environment, take the client to a private room and shut the door. Background noise significantly interferes with hearing in the hearing-impaired client (Ackley & Ladwig, 2011). Communication failure between health professionals and hearing-impaired clients is common (Ackley & Ladwig, 2011). 3. Stand or sit directly in front of the client when communicating. Make sure adequate light is on nurse's face, avoid chewing gum or covering mouth or face with hands while speaking, establish eye contact, and use nonverbal gestures. Clients with hearing impairment read lips and also interpret nonverbal communication, which is a significant part of communication. To increase communication, it is important that the client is able to see the face clearly of the person speaking (Ackley & Ladwig, 2011). 4. Encourage the client to wear hearing aid if available. EB: A study demonstrated that nursing home clients with hearing loss who utilized a hearing aide had decreased level of depression (Ackley & Ladwig, 2011). 5. Teach client to avoid excessive noise at work or at home, wearing hearing protection when necessary. Any noise that hurts the ears or is above 90 decibels is excessive. Hearing loss from excessive noise is common and preventable (Ackley & Ladwig, 2011). 6. Assess pain in a client by using a self-report such as the 0 to 10 numerical pain rating scale. Systematic ongoing assessment and documentation provide direction for the pain treatment plan; adjustments are based on the client's response (Ackley & Ladwig, 2011). 7. Ask the client to describe prior experiences with pain, effectiveness of pain management interventions, responses to analgesic medications including occurrence of adverse effects, and concerns about pain and its treatment (e.g., fear about addiction, worries, or anxiety) and informational needs. EBN: Obtaining an individualized pain history helps to identify potential factors that may influence the client's willingness to report pain, as well as, factors that may influence pain intensity, the client's response to pain, anxiety, and

pharmacokinetics of analgesics (Ackley & Ladwig, 2011). Pain management regimes must be individualized to the client and consider medical, psychological, and physical condition; age; level of fear or anxiety; surgical procedure; client goals and preference; and previous response to analgesics (Ackley & Ladwig, 2011). 8. Manage acute pain using a multimodal approach. Multimodal analgesia combines two or more medications, or methods, from different pharmacological classes that target different mechanisms along the pain pathway, including opioid, nonopioid, and adjuvant analgesics (Ackley & Ladwig, 2011). Specifically, an acute pain multimodal regime may include an opioid, acetaminophen, a nonsteroidal anti-inflammatory drug (NSAID), an anticonvulsant, a local anesthetic, or combinations (Ackley & Ladwig, 2011). The advantage of this approach is that the lowest effective dose of each drug can be administered, resulting in fewer or less severe adverse effects such as over sedation and respiratory depression (Ackley & Ladwig, 2011). 9. Explain to the client the pain management approach, including pharmacological and nonpharmacological interventions, the assessment and reassessment process, potential adverse effects, and the importance of prompt reporting of unrelieved pain. One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role the client needs to play in pain control (Ackley & Ladwig, 2011). 10. Teach and implement nonpharmacological interventions when pain is relatively wellcontrolled with pharmacological interventions. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (Ackley & Ladwig, 2011). 11. Teach the importance of taking pain medications to maintain the comfort-function goal. Teaching clients to stay on top of their pain and prevent it from getting out of control will improve the ability to accomplish the goals of recovery (Ackley & Ladwig, 2011).

References Ackley, B. J. & Ladwig, G. B. (2011). Nursing diagnosis book: An evidence-based guide to planning care. St. Louis, MO: Mosby.