comprehensive versus focused assessment

comprehensive versus focused assessment. Discussion post for this week, please take the following descriptive information and place it with the appropriate categories listed.

comprehensive versus focused assessment

Introduction

Discussion post for this week, please take the following descriptive information and place it with the appropriate categories listed. Based on the descriptive information would this be a focused or comprehensive assessment and if focused what system or systems would you want to assess and why?

Descriptions

• Presents with c/o headache
• Pain is a \’4\’ on a scale of 1-10
• Scoliosis corrected with Charleston brace, broken toe
• No cold/sinus symptoms
• Eye exam 2 years ago
• No medications, NKDA
• No hospitalizations
• No tobacco use, wine once monthly, no recreational drug use
• Single, lives alone
• Traveled to UK, Caribbean in past 3 months
• Throbbing for past 2 hours, can feel pulse in temple
• Sports-induced asthma
• No fever, no changes in vision

Categories

• Chief Complaint
• History of Present Illness
• Past Medical History
• Personal and Social History
• Review of Symptoms

Subjective

• Chief Complaint

Throbbing headache

• History of Present Illness

Patient reports having a throbbing headache over the past two hours and can feel pulse in the temple.

• Past Medical History

She was diagnosed with scoliosis probably in her childhood or adolescent years that was corrected using Charleston brace. She also had a broken toe.

Current medications- the patients is not taking any medications at the present.

NKDA. She reports she has never been ad mitted to a hospital that she knows of.

Reports having sports induced asthma.

• Personal and Social History

The woman lives alone.

She denies using any tobacco products, admits to taking wine at least once a month bbut is negative on recreational use of drugs.

She reports visiting the UK and the Caribbean in the past 90 days.

Objective

• Review of Symptoms
• Constitutional:  , No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise
• ENT/Mouth:  No Hearing Changes, No Ear Pain,  No Sinus symptoms , No Hoarseness, , No Rhinorrhea, normal  Swallowing, No sore throat
• Eyes:  Nothing remarkable , No Vision Changes
• Cardiovascular:  Negative for Chest Pain, SOB, NPND, and Dyspnea on Exertion. Unremarkable.
• Respiratory:  No Cough, Sputum, Wheezing as well as no smoke exposure.
• Gastrointestinal:  No Nausea, No Vomiting, No Diarrhea, No Constipation, No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No Jaundice
• Genitourinary:  Nothing remarkable was reported.
•  Musculoskeletal:  No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No Neck Pain,  Has a history of broken toe Hi
• Skin:  Negative for  Skin Lesions,  Pruritis, Hair Changes, No Breast/Skin Changes, No Nipple Discharge
• Neuro:  No Loss of Consciousness No Weakness, No Numbness, No Paresthesia, No Syncope, No Dizziness, throbbing  Headache,
• Psych:  No Anxiety/Panic, No Depression, No Insomnia, No changes in Personality Changes,
• Heme/Lymph: No Transfusions History, No Bruising, No Bleeding, and  No Lymphadenopathy
• Endocrine:  No Temperature Intolerance, No Polydipsia, and  No Polyuria,

Assessment

            The patient reports a pain scale 4 on a scale of 0-10. This means that using descriptive words, her pain would moderate on the lower side of at 4 not 5 or 6.severe would be in the range of 7-10, while mild spurns from 1 to 3 and none at zero (Atisook et al., 2021). At four, it means the pain can be ignored for some time but is enough to distract the patient from her daily living activities in a significant way.

            Using the descriptive information given, the woman is a relatively healthy individual who is lucky she has not had significant or life-threatening medical issues throughout her life to date.

As such, this would be a focused health assessment meaning it is a detailed nursing assessment of a specific body system herein chosen to be the central nervous system as opposed to a comprehensive nursing assessment demanding the collection of extensive data for the patient as well as her families, groups, and communities.

            I would conduct a focused neurological assessment to provide an additional insightful review of motor and sensory function tests together with cranial nerve testing (Fortner et al., 2018). This is because scoliosis affects the CNS as it involves the spine, which is a significant component of the body’s communication system and is known to cause tension headaches.

References

Atisook, R., Euasobhon, P., Saengsanon, A., & Jensen, M. P. (2021). Validity and Utility of Four Pain Intensity Measures for Use in International Research. Journal of Pain Research, 14, 1129.

Fortner, M. O., Oakley, P. A., & Harrison, D. E. (2018). Alleviation of chronic spine pain and headaches by reducing forward head posture and thoracic hyperkyphosis: a CBP® case report. Journal of physical therapy science, 30(8), 1117-1123.