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NURS 6512 Lab Assignment: Assessing the Abdomen Sample Paper

Abdominal Pain

The subjective portion of the note consists of the following information: the patient is a woman currently complaining of severe abdominal cramping. Significant information that should be included in the subjective note include when did the pain begin? How did it begin; was it gradual or sudden? What is the progress of the pain; is it becoming worse or better? (Dains et al., 2019). What is its character; is it a dull pain, sharp, burning, stabbing or stinging pain? Is the pain radiating or non-radiating? If it is the radiating type, where does it radiate from and to where?

Are there any other symptoms associated with the pain, such as nausea and vomiting? What relieves the pain; does medication, lying in a certain position or sitting in a particular posture alleviate the pain? What increases the pain; does standing, walking or sitting in a certain way augment the pain? What is the timing of the pain? Is it continuous or discontinuous, does the pain come more often during particular times of the day? Does the pain interfere with daily activities such as work, in such a manner that she is unable to continue with her duties?

The objective portion of the note consists of this information: while she had been diagnosed with diverticulitis, a CT scan revealed pancreatic growth that turned out to be pancreatic cancer. Additional information that would be significant should include whether the patient was treated of similar symptoms. In case the response is positive, the nurse should seek information as to what tests were conducted on the patient and what the diagnosis was at the time. Also, the care management approach used in her case would be helpful.

A focused adnominal history would assist in minimizing chances of misdiagnosis. The questions relevant would be how long ago did the pain start? Was the onset gradual or sudden and how severe was the pain on a scale of 1 to 10? Does the pain prevent the patient from engaging in daily tasks/responsibilities? Does she awake from sleep due to the pain? It is also important to know what has been the course of the pain since it started. Is it getting worse or better? When was the last bowel movement? Has she ever had the pain before; if so what was diagnosed, how was it treated?

The focused physical examination will commence with noting the general appearance. Visceral pain often makes patients restless and uncomfortable. An assessment of the vital signs is also mandatory (Dains et al., 2019). The nurse should check out for shallow respirations, tachypnea or tachycardia. Documented weight loss should be noted since the patient has a neoplasm. The nurse should observe the abdominal musculature for features of rigidity, the coloring of the abdominal skin and note any abdominal distention. An auscultation for bowel sounds, percussion for tones and guarding and palpation for masses will also assist in forming a definitive diagnosis for this patient. For this patient, the differential diagnoses include diverticulitis, hernia, costochondritis, Crohn disease, irritable bowel syndrome, esophagitis, uterine fibroids, dysmenorrhea or recurrent UTI.

The assessment is supported by the subjective and objective information. Since the patient complains of chronic pain, conditions presenting with acute pain such as pancreatitis, appendicitis, peritonitis and intestinal obstruction are unlikely. The nurse may rule out these conditions from the differential diagnosis. Also, symptoms such as diarrhea and vomiting may be present in Crohn disease and irritable bowel syndrome. Therefore, their absence may drive the care provider to other conditions. Signs such as tachycardia, tachypnea and shallow breathing if present may indicate presence of metabolic acidosis, where the patient tries to compensate using the respiratory system (LeBlond et al., 2014).

Shallow breathing may further indicate airway obstruction by another underlying illness like pneumonia. Absent bowel sounds are indicative of conditions such as paralytic ileus or partial or total duodenectomy, ileectomy or jejunectomy. Palpation will reveal presence of underlying intraabdominal masses (Ball et al., 2019). In this patient, the growth noted on the pancreas is likely to be palpable. Percussion of the abdomen for this case may not yield positive results unless the spleen and the liver are enlarged. In hepatosplenomegaly, a dull note on percussion may be elicited. Percussion will yield a tympanic note also owing to absence of ascetic fluid in the patient.

Several diagnostic tests will be relevant for this patient. Serum lipase levels should be tested. Serum lipase levels are elevated in pancreatic tumors, and the test is more specific than serum amylase levels. While both lipase and amylase are pancreatic enzymes the later is also found in the saliva. Also, a biopsy of the pancreas for histology, cytology and histocytopathology would assist in the diagnosis. Histocytopathology would note the presence of neoplastic cells and characterize them as malignant or non-malignant (Bharucha et al., 2016). Immunohistochemistry will identify specific tumor markers and give the appropriate medical name of the pancreatic growth. In addition, an MRI of the abdomen will outline the structure and orientation of organs involved (Coylar, 2015), which would provide a visual analysis of the extent of growth and possible metastases. Determining the extent of the tumor assists in staging. Early stage tumors may be managed by chemoradiotherapy or surgical management depending on the tumor type and the patient’s body habitus.

I would accept the current diagnosis of diverticulitis if supported by X-RAY evidence. In addition to the diverticulitis, the patient has pancreatic growth as proven by the CT-Scan. Pancreatic tumor should be part of the diagnosis. Differential diagnoses for this patient include hernia, irritable bowel syndrome and parasitic infection of bowels (Koop et al., 2016; Martelli & Lee, 2016; Bharucha et al., 2016). Hernia presents with pain that may increase on coughing. Hernias may also increase visibly in size when the patient coughs. Parasitic infections would be an unlikely cause since they are rare in developed nations as compared to the developing world.

References

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
• Bharucha, A. E., Chakraborty, S., & Sletten, C. D. (2016). Common functional gastroenterological disorders associated with abdominal pain. Mayo Clinic Proceedings, 91(8), pp. 1118-1132. https://doi.org/10.1016/j.mayocp.2016.06.003
• Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
• Koop, H., Koprdova, S., & Schürmann, C. (2016). Chronic abdominal wall pain: a poorly recognized clinical problem. Deutsches Ärzteblatt International, 113(4), 51. https://dx.doi.org/10.3238%2Farztebl.2016.0051
• LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
• Martelli, M. G., & Lee, J. Y. (2016). Parasitic Infection of the Gallbladder: Cystoisospora belli Infection as a Cause of Chronic Abdominal Pain and Acalculous Cholecystitis. Journal of the Mississippi State Medical Association, 57(6), 174-176

Assessment-Dashboard Metrics Evaluation Sample Paper

Healthcare institutions endeavor to improve care quality and safety and reduce costs through periodic evaluation and intervention. A major organizational assessment method is through dashboards. Comparing the dashboard metrics helps healthcare institutions note the underperforming areas and provokes the development of interventions to improve them. Dashboards can be internally or externally prepared.

Internal dashboards help organizations evaluate their performance over time, while external dashboards help them compare their performance against other institutions and national standards. Internal dashboards are the best in determining an institution’s progress over time, and they can also be compared against set benchmarks to show the institution’s performance relative to other organizations. Mercy Medical Center is the hospital of interest.

It is Villa Health-Affiliated and a renowned hospital for its quality care, as reflected in its various achievements such as outstanding patient experiences, high safe surgery ratings, and best emergency services (Vila Health, n.d.). Mercy Medical Center’s diabetes dashboard metrics are the focus of this assessment. It will also evaluate its performance, relevant local, state, and federal policy challenges in meeting the benchmarks, and develop an ethical intervention to address the poorly performing benchmarks.

Mercy Medical Center Dashboard Metrics Evaluation

The services offered by a healthcare institution may differ depending on the population characteristics. Mercy Medical Center is a large institution serving over 20,000 individuals. The hospital serves 2371 over 65 years, 6099 aged 45-64, 14732 aged 21-44, and 12 126 under 20 years (Vila Health, n.d.). The ethnic and racial distribution from the largest to the smallest group is as follows: whites 28537, Asians 3822, Hispanic Latino 2890, African Americans 1601, interracial 1016, American Indian 4333, and other ethnicities 11611. The region’s total population is 36192, and the gender distribution is 17957 males and 18235 females. Race, age, and gender are important factors in diabetes management.

Mercy Medical Center’s public diabetes dashboard is evaluated quarterly, and the institution evaluates its performance for each quarter. The data is presented based on gender, age, and race and includes the number and percentage changes relative to the total number of diabetic patients. 2019’s last quarter statistics were as follows: 355 whites (63%), 34 Asians (6%),73 American Indians (13%), 17 African Americans (3%), 11 other races (2%), and 73 did not respond (Vila Health, n.d.). Of these, 214 patients were males (38%), while 347 (62%) were female, and two did not respond to the gender question.

Among them, 118 were below 20 years, 51 were between 21 and 44, 214 were between 45 and 64, and 180 patients were 65 years and above (Vila Health, n.d.). The government requires individuals to attend an annual diabetic foot, eye, and HbA1c examination. The rates of HbA1c have been dropping gradually, and the number of diabetic foot exams has been relatively low. These rates are relatively low and cause concern, judging from the number of new patients for the last quarter. There are several areas of missing information.

The total number of patients available makes it difficult to calculate the percentage of patients attending diabetic foot, eye, and HbA1c examinations. In addition, other diabetes interventions vital to diabetes monitoring, such as diabetes complications and their categories that help show the actual impact of the benchmarks, are missing.

Benchmarks Set Forth by Local, State, & Federal Laws

Benchmarking is an important way of evaluating performance. Comparing the organization’s performance against the national and state-set standards will help gauge the organization’s success in meeting healthcare needs. These standards help maintain high-quality care and spearhead quality improvement processes in healthcare institutions. Institutions can borrow ideas from other organizations succeeding in various benchmarks to improve care delivery, quality, and patient safety associated with the benchmark of choice.

The Agency for Healthcare Research and Quality is responsible for preparing national quality standards for various healthcare conditions. AHRQ relies on data sources such as the National Committee on Quality Assurance, DART Net, and SAFTINet, large data organizations with high efficiency, specialization, and reliability (AHRQ, 2021). The agency liaises with other bodies responsible for specific conditions, such as the American Heart Association (stroke and heart disease) and the American Diabetes Association (diabetes), to collect and analyze data vital in preparing these benchmark dashboards.

AHRQ prepares annual reports that contain specific dashboards for managing various healthcare conditions and certain conducts within the hospital. The National Healthcare Quality and Disparities Report is a comprehensive document prepared each year to reflect the data collected and analyzed and the inferences made by the AHRQ. The national diabetes quality measures by the NHQDR feature the national benchmarks for diabetes on dilated eye and foot exams and HbA1c tests.

AHRQ (n.d.) notes that these benchmarks are results from top-performing institutions, and other institutions can gauge their performance using them. NHDQR (2019) report states that more than 79.5% of diabetic patients should take the HgbA1c test twice annually, more than 84% of patients should take annual diabetic foot tests, and more than 75.2% of patients should take annual eye exams (AHRQ, n.d.). These percentages are set from the results of the best-performing healthcare institutions. These tests are integral to detecting patient complications early and intervening before injury results in the patient.

Challenge Posed by Meeting Prescribed Benchmarks

Meeting the prescribed benchmarks would pose a challenge to healthcare staffing. Diabetes patients place a significant burden on the healthcare workers’ workload. Winter et al. (2020) note that a global healthcare staff shortage affects most hospitals. Meeting the benchmark will increase the number of patients attending the hospital, further aggravating the shortage of healthcare staff due to the increased demand.

Available staff in hospitals with staff shortages focus more on completing the assigned tasks than ensuring quality care. It is thus easy for them to overlook some items, such as annual checkups, despite their potential to influence diabetes patient outcomes. Understaffing increases error incidences, interferes with work productivity, and promotes high employee fatigue and burnout, high employee turnover, and poor patient outcomes (Winter et al., 2020).

The few staff can also overlook the comprehensive and keen patient assessment. Pankhurst & Edmonds (2018) state that staff shortage leads to decreased staff efficiency and reliance; hence, it is easy to overlook details such as changes in HbA1c test variations, wounds and minor injuries, and slight changes in visual acuity when attempting to complete the many tasks.

Patient education is a vital aspect of diabetes management. With inadequate staff, there is limited time to emphasize the importance of these follow-ups, leading to low patient turnout. Understaffing would thus affect the quality of care and increase patient safety issues. Healthcare staff shortages are a global pandemic, and very few hospitals have nurses and physicians close to the recommended health worker-to-patient ratio (Winter et al., 2020). The problem affects government and private institutions. A major assumption is that Mercy Medical Center is also affected by the global healthcare staff shortage.

HbA1c tests are integral in determining the effectiveness of interventions in managing blood glucose levels within acceptable limits. Imai et al. (2021) state that tests help with interventions such as changes in patient therapy, patient education, and family involvement in cases of self-care deficit. HbA1c tests help detect complications and impaired glucose regulation early; thus, healthcare providers intervene early to prevent complications.

Imai et al. (2021) also note that patients with strict adherence to HbA1c tests have better outcomes and effectiveness in glycemic control. Failure to monitor HbA1c leads to complications such as persistent high blood glucose, peripheral neuropathies, and stroke. It thus decreases care quality and interferes with patient safety, hence poor population health. HbA1c tests and results monitoring are thus integral.

Ethical Intervention for the Underperforming Benchmark

The stakeholder group to take action is the healthcare leaders. The leaders prepare policies and can easily organize and provide resources for any intervention in the healthcare institution. Diabetes management requires the input of various professionals, including nurses, doctors, ophthalmologists, and laboratory technicians, and these professionals interact with the patients to varying degrees. The chosen intervention, staff education, is an integral step in ensuring that patients understand the importance of HbA1c tests and other metrics in diabetes management. The main goal is to increase the patient’s knowledge and promote healthy behavior. Researchers note that staff training increases their confidence, the immediacy of action, quality healthcare decisions, and patient safety and promotes better staff work experiences (Torani et al., 219).

Ethics in healthcare are integral. Respecting autonomy and fidelity are the basis for developing the intervention. The main goal is to increase the patients’ knowledge to make the right decisions (Lambrinou et al., 2019). Patients also participate in healthcare decisions when they understand their implications. The education will also remind the nurses of the importance of carrying out the tests and encourage them to meet the requirements when managing these patients. The education will increase their faithfulness when assessing and educating these patients to ensure adherence to the diabetes management requirements. Comprehensive education will also help improve other standards, such as vaccination requirements not included in this dashboard.

Most initiatives and emphasis on healthcare interventions are initiated by healthcare providers, thus sensitizing the nurses to the benchmarks and reminding them of the importance of teaching patients. Reminding nurses will help manage the underperforming benchmark and prevent further complications while ensuring the interventions do not stretch the existing healthcare resources. Other interventions that can supplement the intervention include preparing learning material such as handouts and online resources, and referring patients to them will further increase their information and create the need and urgency to adhere to the recommendations of HbA1c tests (Ghisi et al., 2021).

Conclusion

Dashboard evaluation helps in healthcare performance and quality improvement. These healthcare dashboards help determine progress and show the hospital’s performance to other institutions and the nationally set standards. Mercy Medical Center’s diabetes dashboard metrics show the need for interventions to improve HbA1c tests. The tests are poorly done compared to the nationally set standards. The lack of statistics on the total number of patients makes it difficult to calculate actual percentages. Moreover, eye exams and diabetic foot exams are also performing poorly, and there is room for improvement. The intervention to improve the underperforming dashboard metric is based on various ethical principles, including autonomy, respect for persons, and fidelity. Staff training will help improve the underperforming benchmark and overall diabetes management.

References

• Agency for Healthcare Research and Quality. (n.d.). National Healthcare Quality and Disparities Report 2021. The National Diabetes Quality Measures. Accessed 30th June 2022 from https://nhqrnet.ahrq.gov/inhprdr/national/benchmark/table/diseases_and_conditions/diabetes
• Agency for Healthcare Research and Quality. (n.d.). Practice Facilitation Handbook, Module 7. Measuring and Benchmarking Clinical Performance. AHRQ. Agency for Healthcare Research and Quality. Accessed 30th June 2022 from https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod7.html
• Ghisi, G. L. D. M., Seixas, M. B., Pereira, D. S., Cisneros, L. L., Ezequiel, D. G. A., Aultman, C., Sandison, N., Oh, p., & da Silva, L. P. (2021). Patient education program for Brazilians living with diabetes and prediabetes: findings from a development study. BMC Public Health, 21(1), 1-16. https://doi.org/10.1186/s12889-021-11300-y
• Imai, C., Li, L., Hardie, R. A., & Georgiou, A. (2021). Adherence to guideline-recommended HbA1c testing frequency and better outcomes in patients with type 2 diabetes: a 5-year retrospective cohort study in Australian general practice. BMJ Quality & Safety, 30(9), 706-714. http://dx.doi.org/10.1136/bmjqs-2020-012026
• Lambrinou, E., Hansen, T. B., & Beulens, J. W. (2019). Lifestyle factors, self-management and patient empowerment in diabetes care. European Journal Of Preventive Cardiology, 26(2_suppl), 55-63. https://doi.org/10.1177/2047487319885455
• Pankhurst, C. J. W., & Edmonds, M. E. (2018). Barriers to foot care in patients with diabetes as identified by healthcare professionals. Diabetic Medicine, 35(8), 1072–1077. https://doi.org/10.1111/dme.13653

Assessment 4 Instructions Final Care Coordination Plan

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Adapt care based on patient-centered and person-focused
  • Design patient-centered health interventions and timelines for a selected health care
• Competency 2: Collaborate with patients and family to achieve desired
  • Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes

based upon evidence-based practice.

• Competency 3: Create a satisfying patient
  • Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020
• Competency 4: Defend decisions based on the code of ethics for
  • Consider ethical decisions in designing patient-centered health

• Competency 5: Explain how health care policies affect patient-centered
  • Identify relevant health policy implications for the coordination and continuum of
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and

Preparation

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2020.

Instructions

Note: You are required to complete Assessment 1 before this assessment. For this assessment:

• Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA formatted paper, 5–7 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

• Design patient-centered health interventions and timelines for a selected health care
  • Address three health care
  • Design an intervention for each health
  • Identify three community resources for each health
• Consider ethical decisions in designing patient-centered health interventions.

• Consider the practical effects of specific
• Include the ethical questions that generate uncertainty about the decisions you have

• Identify relevant health policy implications for the coordination and continuum of
  • Cite specific health policy provisions.
• Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

• Clearly explain the need for changes to the plan

• Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document.

• Use the literature on evaluation as guide to compare learning session content with best
• Align teaching sessions to the Healthy People 2020

• Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
• Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling

Additional Requirements

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

14 to >13.0 pts

LACHANDA BROWN: Hello

Assessment of Nutrition in Children NURS 6512

CASE STUDY ASSIGNMENT: ASSESSMENT OF NUTRITION IN CHILDREN

When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors in order to select the most appropriate test or tool and to accurately interpret the results.

Not only do these diagnostic tests affect adults, body measurements can provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process.

For this Assignment, you will  consider examples of children with various weight issues. You will explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight.

TO PREPARE

• Review this week’s Learning Resources and consider factors that impact the validity and reliability of various assessment tools and diagnostic tests. You also will review examples of pediatric patients and their families as it relates to BMI.
  • Based on the risks you might identify consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
  • Consider how you could encourage parents or caregivers to be proactive toward the child’s health.

THE ASSIGNMENT

Assignment (3–4 pages, not including title and reference pages):

Assignment: Child Health Case:
Include the following:

• An explanation of the health issues and risks that are relevant to the child you were assigned.
• Describe additional information you would need in order to further assess his or her weight-related health.
• Identify and describe any risks and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
• Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information.
• Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight.

BY DAY 6 OF WEEK 3

Submit your Assignment.

LEARNING RESOURCES

Assessment of Nutrition in Children NURS 6512 Required Readings

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
  • Chapter 3, “Examination Techniques and Equipment”
    This chapter explains the physical examination techniques of inspection, palpation, percussion, and auscultation. This chapter also explores special issues and equipment relevant to the physical exam process.
  • Chapter 8, “Growth and Nutrition”
    In this chapter, the authors explain examinations for growth, gestational age, and pubertal development. The authors also differentiate growth among the organ systems.

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Student checklist: Health history guide Download Student checklist: Health history guide. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
  Credit Line:  Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
• Centers for Disease Control and Prevention. (2021, April 9). Childhood overweight & obesity. http://www.cdc.gov/obesity/childhood/
  This website provides information about overweight and obese children. Additionally, the website provides basic facts about obesity and strategies to counteracting obesity.
• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
  Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
  • Chapter 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom Analysis”
    This chapter introduces the diagnostic process, which includes performing an analysis of the symptoms and then formulating and testing a hypothesis. The authors discuss how becoming an expert clinician takes time and practice in developing clinical judgment.

• Nyante, S. J., Benefield, T. S., Kuzmiak, C. M., Earnhardt, K., Pritchard, M., & Henderson, L. M. (2021). Population?level impact of coronavirus disease 2019 on breast cancer screening and diagnostic procedures. Cancer, 127(12), 2111–2121. https://doi.org/10.1002/cncr.33460
• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). History subjective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
  Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.

• Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
  • Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Week 1)
  • Chapter 5, “Pediatric Preventative Care Visits” (pp. 91 101)

Assessment of Nutrition in Children Example

In considering the case of a 2-year-old girl of normal weight who resides with her obese mother and normal-weight father, it is important to delve into the various health issues and risks she may encounter. This scenario presents a unique blend of genetic, environmental, and behavioral factors that could influence the child’s future health. This family dynamic presents a multifaceted view of health risks and considerations, primarily influenced by genetic, environmental, and behavioral factors. Genetically, a child may inherit a predisposition to obesity from her mother despite having a normal weight during infancy (Cavalli & Heard, 2019). This genetic factor underscores the importance of vigilance in her health management as she grows.

Environmentally, the child’s exposure to her mother’s obesity could influence her own health behaviors. Dietary habits within the household, driven by the mother’s choices, might lean towards unhealthy patterns, posing a risk to the child’s nutritional status. Conversely, the presence of a father with a normal weight provides an opportunity for balanced dietary and lifestyle modeling. Behaviorally, the child is at a critical stage where habits are formed. The mixed health status of her parents could lead to inconsistent health behaviors, which, according to Milne-Ives et al. (2020), emphasizes the need for structured guidance in her diet and physical activity. Additionally, the psychosocial aspect of living with an obese parent could impact the child’s self-esteem and body image, making supportive and positive family dynamics crucial.

Additional information is needed in several key areas to further assess the 2-year-old girl’s weight-related health. Firstly, a detailed family health history would be essential, especially concerning any chronic diseases like diabetes, heart conditions, or obesity-related complications in both the maternal and paternal lineage. This information would offer insights into the genetic predispositions the child might have. Secondly, understanding the dietary habits of the household is crucial. Details about the types of foods regularly consumed, meal patterns, portion sizes, and the balance of nutrients would provide a clearer picture of a child’s nutritional intake (Sheldrick et al., 2019), which is crucial in this case. Information about the mother’s eating habits, given her obesity, would be particularly relevant in assessing the potential influence on the child’s diet.

Physical activity levels are also important. Data on how often the child engages in physical play, the types of activities she participates in, and the overall sedentary versus active time spent daily would help evaluate her physical health and development needs. According to Sheldrick et al. (2019), a child’s developmental milestones and current growth metrics, such as weight-for-age and height-for-age ratios, are vital. These would help determine if she is on track with expected growth patterns for her age. Additionally, understanding the family’s socio-economic status could provide context, as it often influences access to healthy food options and recreational activities. Lastly, information on the family’s general attitude and knowledge about health, nutrition, and physical activity would help assess the likelihood of the child adopting healthy lifestyle habits.

Several risks are primarily related to potential genetic predispositions and environmental influences on the child’s health. The child may be at a higher risk of developing obesity due to genetic factors, given her mother’s obesity. Additionally, the family’s dietary and lifestyle habits could significantly influence the child’s long-term health, with potential risks including poor nutrition, inadequate physical activity, and the development of unhealthy eating behaviors. To fully understand the child’s health, collecting more information in a sensitive and non-intrusive manner is necessary. Detailed family health history, particularly concerning obesity-related conditions (Sheldrick et al., 2019), would be crucial for this case.

Understanding the family’s daily dietary practices, meal routines, and physical activity patterns would provide insight into the child’s lifestyle. Monitoring the child’s developmental milestones and growth parameters would also be essential to assess her physical development accurately. Gathering this information could be approached sensitively through regular pediatric consultations where the healthcare provider can gently inquire about family health history, dietary habits, and lifestyle practices. Using routine health check-ups as an opportunity for education and guidance on nutrition and physical activity can also be beneficial. Engaging with the family in a supportive, non-judgmental manner is key to encouraging openness and cooperation and ensuring the child’s health is monitored and supported effectively.

Specific Questions

1. Nutritional Inquiry: Could you tell me about your child’s favorite foods and meals? What does a typical day of eating look like for her?
2. Activity Level: What activities or games does your child enjoy? How does she like to spend her playtime?
3. Family Health Patterns: Are there any common health concerns or conditions in your family history that you think we should be aware of for your child’s overall health?

Strategies

One effective approach is to focus on family-centric health education. This involves engaging the family in discussions about the importance of healthy eating and physical activity tailored to their specific situation. The family can be guided towards healthier eating habits by providing practical advice on preparing balanced meals that meet both the child’s growth needs and the mother’s health requirements (Patel et al., 2021). Additionally, suggesting family-oriented physical activities that everyone can participate in, like evening walks or weekend outings to the park, can foster a positive environment for the child’s physical development.

Another strategy is to leverage the role of the normal-weight father as a positive influence. Encouraging him to lead by example in adopting healthy behaviors can have a ripple effect on the entire family. This could include involving the father more in meal planning and preparation, emphasizing the importance of his role in shaping the child’s dietary habits. Similarly, initiating family-wide lifestyle changes, such as setting aside time for joint physical activities or play, benefits the child and provides an opportunity for the obese mother to engage in healthier behaviors (Milne-Ives et al., 2020). By fostering an inclusive and supportive family environment, these strategies aim to encourage long-term, sustainable changes that will positively impact the child’s health and well-being.

Assessment of Nutrition in Children NURS 6512 References

Cavalli, G., & Heard, E. (2019). Advances in epigenetics link genetics to the environment and disease. Nature, 571(7766), 489–499. https://doi.org/10.1038/s41586-019-1411-0

Konttinen, H. (2020). Emotional eating and obesity in adults: the role of depression, sleep and genes. Proceedings of the Nutrition Society, 79(3), 283-289. https://doi.org/10.1017/S0029665120000166

Milne-Ives, M., Lam, C., De Cock, C., Van Velthoven, M. H., & Meinert, E. (2020). Mobile apps for health behavior change in physical activity, diet, drug and alcohol use, and mental health: systematic review. JMIR mHealth and uHealth, 8(3), e17046. https://doi.org/10.2196/17046

Patel, B. P., Hadjiyannakis, S., Clark, L., Buchholz, A., Noseworthy, R., Bernard-Genest, J., & Hamilton, J. K. (2021). Evaluation of a pediatric obesity management toolkit for health care professionals: A quasi-experimental study. International Journal of Environmental Research and Public Health, 18(14), 7568. https://doi.org/10.3390/ijerph18147568

Sheldrick, R. C., Schlichting, L. E., Berger, B., Clyne, A., Ni, P., Perrin, E. C., & Vivier, P. M. (2019). Establishing new norms for developmental milestones. Pediatrics, 144(6). https://doi.org/10.1542/peds.2019-0374

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

• Shadow Health. (2021). Welcome to your introduction to Shadow HealthLinks to an external site.. https://link.shadowhealth.com/Student-Orientation-Video
• Shadow Health. (n.d.). Shadow Health help deskLinks to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us
• Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
• Document: Shadow Health Nursing Documentation Tutorial Download Shadow Health Nursing Documentation Tutorial(Word document)

Required Media

Taking a Health History

[music playing]

NARRATOR: Nurses play a critical role in gathering information and assessing a patient’s health.

MARIANNE SHAUGHNESSY: The health assessment is one of the most critically important pieces of our patient interaction.

NARRATOR: With more demands on their time, this critical step can suffer.

MARIANNE SHAUGHNESSY: Certainly, practicing nurses are extremely busy people. But if you rush through a health interview or a patient interview, chances are good there’s going
to be information you’re going to miss. And if that information is missed, the consequences could be dire for the patient.

NARRATOR: Doctor Marianne Shaughnessy shares her expertise on how to conduct an in-depth health assessment interview, and provides a demonstration of effective strategies. [music playing]

MARIANNE SHAUGHNESSY: Capturing all health-related information in a systematic way,
documenting that information, creates a foundation, a database, for us to build upon. In fact, all members of the healthcare team can utilize the nursing database if it’s well-constructed and contains the information necessary to then build a plan for managing a patient’s health in conjunction with the patient over the course of time. [knock knock]

MS. HUDGENS: Come in.

MARIANNE SHAUGHNESSY: Ms. Hudgens?

MS. HUDGENS: Yes.

MARIANNE SHAUGHNESSY: Good morning. My name is Marianne Shaugnessy. I’m a nurser practitioner, and I’ll be doing your history and physical this morning.

MS. HUDGENS: Good, thank you.

MARIANNE SHAUGHNESSY: It’s nice to meet to you.

MS. HUDGENS: Nice meeting you.

MARIANNE SHAUGHNESSY: When I walked into the room, I was able to immediately
established a rapport with the patient by speaking with her cordially but professionally. When starting an interview with a patient, it’s very important to try and establish an environment that is conducive to communication. We’ve all been in doctors’ offices with exam rooms that have paper thin walls where you can hear noise on either side.

We’d like to try and avoid that as much as possible by providing an environment in which a patient feels safe to open up and talk, and has a reasonable expectation that it’ll be private. Good morning. You walk into a room, sit down, calmly relax and establish eye contact. That sends a message to a patient that you have all the time in the world for them, and as nurses that’s rarely actually the case.

It’s also important, if you can, to make sure to be on eye-level with the patient, and to try and avoid the superior position, where you are looking down on a patient. We started with some very global, open-ended questions. So what brings you in today?

MS. HUDGENS: Well, we haven’t had insurance for awhile. My husband was laid off, but we have insurance now, so I just wanted to kind of cover a couple of things, get a physical.

MARIANNE SHAUGHNESSY: Great. OK. Have you been feeling well? Find out first what’s
on the patient’s mind, because that’s why they’re there, and it’s critical to address the issues of importance in the patient’s mind, whether or not those issues actually may be the most
life-threatening issues. We move the interview from open-ended questions to closed-ended
questions, and by that I mean asking the patient to embellish or talk more about a particular concern.

OK, then I need to ask you about some exposure in your early years. The reason that the
history was so in-depth is because it’s important to capture not only what the patient is telling you they want to address when they come in for an appointment, but also to do some routine surveillance and screening to capture issues that patients may not even be aware of. Do you have any history of anemia in the past?

MS. HUDGENS: No, I haven’t.

MARIANNE SHAUGHNESSY: OK. OK. Have you been having any problems with fatigue?

MS. HUDGENS: No, there’s been stress, but other than the stress, really, no fatigue.

MARIANNE SHAUGHNESSY: Weakness?

MS. HUDGENS: No, I’ve been OK.

MARIANNE SHAUGHNESSY: So your energy levels are normal?

MS. HUDGENS: Yes.

MARIANNE SHAUGHNESSY: All right. Have you noticed any problems with unusual bruising?

MS. HUDGENS: Bruising? No.

MARIANNE SHAUGHNESSY: No? OK. And your periods are regular?

MS. HUDGENS: Well, I’m 48 so they’re becoming irregular a little bit, and I’m a little bit heavier. I have a family history of uterine fibroids, and I think that might be coming up with me, too.

MARIANNE SHAUGHNESSY: OK. In terms of this particular interview, the patient brought up a
number of significant points, primarily concerns about anemia, which ordinarily could be caused by any number of things, and it wasn’t until I began to question her about her aspirin use that I became very suspicious that her anemia may actually be caused by a GI bleed as opposed to iron deficiency anemia, which is so very common in women. Are you taking any medication?

MS. HUDGENS: No, not at this time.

MARIANNE SHAUGHNESSY: None whatsoever?

MS. HUDGENS: No.

MARIANNE SHAUGHNESSY: How about over the counter?

MS. HUDGENS: Over the counter [inaudible] aspirins or Tylenol when I get a headache
or leg aches, or–

MARIANNE SHAUGHNESSY: You’re not simply asking a question, and accepting a yes or no answer, and moving on to the next question because it’s very important to follow up with probing questions when a patient reports a positive finding. Do you take aspirin or do you take Tylenol?

MS. HUDGENS: Usually just aspirin.

MARIANNE SHAUGHNESSY: OK. How many times a week are you taking it?

MS. HUDGENS: About two time– a couple of times a week.

MARIANNE SHAUGHNESSY: And how much do you take?

MS. HUDGENS: Just the two that the label says. If I need–

MARIANNE SHAUGHNESSY: Regular adult strength, right?

MS. HUDGENS: Yes.

MARIANNE SHAUGHNESSY: OK. So you’re taking probably 650 milligrams, two 325 milligram tabs.

MS. HUDGENS: OK. MARIANNE SHAUGHNESSY: OK, twice a week. OK. We’re going to need
talk a little bit more about that aspirin, especially in light of your anemia. The most common
mistake that’s made is rushing through it, because we all have multiple demands on our time at any given moment.

Certainly practicing nurses are extremely busy people, but if you rush through a health interview, or a patient interview, chances are good there’s going to be information you’re going to miss, and if that information is missed, the consequences could be dire for the patient. If you take your time, use a systematic approach, and probe the positive responses
for additional information, nine times out of 10 you’ll capture all the information you need in order to help complete a comprehensive database and have a structure, then, for advancing
management and treatment strategies.

Please forgive my note taking, I’m just trying to organize the information as it’s coming in. When you’re performing a health assessment, there’s going to be a certain degree of note taking. You have to. Patients are divulging a lot of information. Once you get into the habit
of taking a health assessment, you can actually reduce your note taking to a minimum. However, a little bit of note taking is fine. You want to make sure not to lose the eye contact that you’ve established with the patient, because that goes a long way toward building rapport. It’s perfectly fine, as you get to know a person, to relax a little bit and have a cordial and friendly interchange.

MS. HUDGENS: My younger sister had the melanoma when she was in her 30s. She worked at the lake with me several years.

MARIANNE SHAUGHNESSY: Ah. Lifeguards, were you?

MS. HUDGENS: Well, close to it, yes.

MARIANNE SHAUGHNESSY: However, it’s very important for the professional nurse to maintain a professional demeanor, and make sure that the questions that she’s asking patients, the responses that she’s recording, and additional questions that she’s asking stay within the realm of professional nursing practice.

MS. HUDGENS: My husband said that there’s a spot on my back that looks a little funny. I’ve had other moles taken off before and they were never cancerous, but I just wanted to have that checked out.

MARIANNE SHAUGHNESSY: The baccalaureate prepared nurse has advanced skills in terms of capturing depth of information. For example, when this morning’s patient told me that she had a history of sun exposure, and now had a lesion of concern on her back, that led to probing questions about the history of early sun exposure and prior mole identification and removal. Also looking for pathologies of lesions that had been removed in the past. Let’s talk a little bit about the mole on your back. Do you have– you mentioned that you had some moles removed previously.

MS. HUDGENS: Yes.

MARIANNE SHAUGHNESSY: And how long ago are we talking?

MS. HUDGENS: I had one removed off of my leg just about four years ago.

MARIANNE SHAUGHNESSY: Mmhm. And the pathology on that, do you–?

MS. HUDGENS: They said it was fine. There was no problems with it.

MARIANNE SHAUGHNESSY: OK.

MS. HUDGENS: But my sister does have– did have a history of melanoma, and so I’m always worried about it.

MARIANNE SHAUGHNESSY: OK. Let’s talk a little bit about your sun exposure.

MS. HUDGENS: I grew up in Phoenix.

MARIANNE SHAUGHNESSY: You did?

MS. HUDGENS: Yes, and lots of time on the water, lot of sunburns. I spent a couple of summers working at the lake, and didn’t take care of it very well.

MARIANNE SHAUGHNESSY: And you only apply sunscreen if you’re going to be going outside?

MS. HUDGENS: Yes.

MARIANNE SHAUGHNESSY: OK. What number do you use?

MS. HUDGENS: 15.

MARIANNE SHAUGHNESSY: OK. Well, for somebody like you we would recommend that
you actually go up to 30 or above and every day.

MS. HUDGENS: OK.

MARIANNE SHAUGHNESSY: It’s very important to take every opportunity to pull in health promotion strategies. In this interview, we utilized not only the opportunity to educate the patient about SPF, but also weight loss, diet, exercise. I take every opportunity to work health promotion strategies into every interaction with a patient whenever I can. Would you like to try and lose some weight?

MS. HUDGENS: Yes.

MARIANNE SHAUGHNESSY: OK. Well, we can talk more about that, because I can provide you with some– a recommended diet for you to follow if you’re interested in doing that. When you’re dealing with sensitive issues in general, the communication strategies really do come into play. It’s very important to watch the tone of your voice so that you’re not in any way conveying a judgment, but allowing them to openly communicate and share with you what
sensitive issues they feel comfortable disclosing. OK, and your fourth pregnancy?

MS. HUDGENS: The fourth pregnancy I was 23, and that did end in a termination. My husband was laid off at the time, so we chose to terminate the pregnancy.

MARIANNE SHAUGHNESSY: OK. I think one thing that I would caution RNs about is you know that the time you need to set aside to do an interview with a younger person is going to be significantly different from the time you need to set aside to do with an older person. In the world of gerontology, it wouldn’t be unusual at all for an interview like that to go upwards of 45 minutes, and would include a lot more questions about functional assessment, day to day activities, cognitive status, and things like that that can impact the life of a senior.

If you work in a setting where you have patients from a number of different cultures, you learn very quickly what the issues are surrounding health care, patient interviewing, physical exams, how someone is either willing or unwilling to disrobe for a man or woman in the room,
about their comfort level with making eye contact.

All of those things are very setting-dependent, but the nurse who’s working, no matter where, has to be aware that some of these influences can come into play at any time and keep the radar up for when those issues may come into play, because the most important thing is making sure that the patient is comfortable. We’re going to go back to the review of systems. I’m going to go from head to toe.

MS. HUDGENS: OK.

MARIANNE SHAUGHNESSY: All right? And we’re going to start with your general, overall health. Have you noticed in the last six months any changes in your weight?

MS. HUDGENS: No. MARIANNE SHAUGHNESSY: The review of systems is the close of the interview. It’s a final opportunity to capture any issues that may have been missed to that point in the interview. The laws vary according to state in terms of mandatory reporting
for domestic violence, but it’s critically important to make sure and ask that screening
question, which I asked at the end of the interview.

And the last question is are there any times that you don’t feel safe at home? That’s a very globally worded question, but it allows the door to be opened. OK, you’re afraid of falling. OK. OK, I have to– I ask that question of everyone only because you never know.

I always conclude an interview by asking a patient, is there anything else you wanted to discuss that we have not yet discussed? The reason for this is I’m trying to avoid what we typically refer to as a doorknob agenda item, meaning when you’ve completed the interview, given the patient a gown, and asked them to undress for the physical exam, as you’re moving
toward the door, as you place your hand on the doorknob, a patient will sometimes say, oh, yes, there’s one more thing.

Now, before we wrap up the interview, are there any other issues that you want to talk about that we have not yet discussed?

MS. HUDGENS: No, I think that’s all.

MARIANNE SHAUGHNESSY: OK. All right, then. Well, we’re going to go ahead and proceed to your physical exam, then.

MS. HUDGENS: OK, great. Thank you.

MARIANNE SHAUGHNESSY: So once the interview is complete, it guides your physical examination. By talking to a patient, you can identify 90% of what your physical exam is going to need to be. Students are very, very focused on learning techniques that are involved
in physical exam, and they sometimes tend to ignore the interview. But the interview is probably the most critical component. That’s where you start– with what the patient tells you.

Somewhat ironic, I think, that most of the physical assessment textbooks really do emphasize
the physical assessment aspect much more so than the interview, when the interview actually plays such a critical role in establishing where things go moving forward in terms of physical exam techniques that are chosen from that point forward, and from specific systems
that a provider may need to pay special attention to.

That information is captured in the interview, and in the health history. There’s always a great deal of professional satisfaction derived from capturing information, from making someone