The Health History and Physical Assessment

Nursing assessments of patients can be discussed as well-structured activities which are based on following a certain protocol (Clarke, 2014). The effectiveness of a health and physical assessment can influence the quality and appropriateness of the proposed treatment (Kohtz, Brown, Williams, & O’Connor, 2017). The purpose of this paper is to comment on the PowerPoint Presentation, which provides the health history and physical assessment of a female patient, while analyzing the appropriateness of the assessment in terms of its organization and collected data.

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In the PowerPoint Presentation, demographics and vital signs related to the patient are presented adequately, but the information on a birthplace and occupation can also be important. It is also important to note that the reason for a visit is stated, but it lacks information regarding possible complaints or other comments associated with the patient’s state (Papathanasiou, Kleisiaris, Fradelos, Kakou, & Kourkouta, 2014).

In the history of present illness (HPI), the author of the presentation offers the information in chronological order, but it lacks the analysis of symptoms and qualities of pain experienced by the patient (Almario et al., 2015; Skeff, 2014). The slides providing the information regarding the results of MRI scanning and medications seem to lack details in spite of the presented notes. The personal medical history of the patient is described with required details. The family and social history is described appropriately, but the data on the presence or absence of diseases related to the patient’s complaints and hospitalization can be required (Carranza-Mamane et al., 2015; Minen, Loder, Tishler, & Silbersweig, 2016; Moriarty & Mallick-Searle, 2016; Papaleontiou & Cappola, 2016).

The review of systems (ROS) is presented on several slides, and this approach allows for describing the data regarding each system in detail. The assessment of systems (AOS) is presented with all required points, but some explanation regarding the collected data is expected to be included in the notes, especially, with the focus on examining those systems which are associated with the patient’s complaints or symptoms.

The plan of treatment which is based on the provided diagnoses can be viewed as incomplete in spite of the fact that all diagnoses are mentioned, and required modifications or directions for the treatment are identified. Still, more details should be included in the plan to mention not only pharmacologic strategies but also non-pharmacologic ones (Moriarty & Mallick-Searle, 2016; Papaleontiou & Cappola, 2016; Vilos et al., 2015).

The notes include the important information regarding the proposed treatment options with the focus on recommendations provided by an obstetrician-gynecologist, but some important points can be viewed missing. Thus, it is possible to add the detailed assessments of the proposed diagnoses with reference to the results of the ROS and AOS and explain why the recommended treatment strategies will be effective for this patient.

While concluding about the overall effectiveness of the PowerPoint Presentation, it is possible to state that it is professional, and it covers the major topics required to be included according to the Health History and Physical Assessment Form. However, the presentation lacks detailed narratives to be provided in notes for each slide, and this aspect limits the understanding of the data presented on slides. Therefore, in order to avoid making slides filled in with unnecessary details, it is possible to recommend utilizing notes and provide all required explanations. Furthermore, the proposed diagnoses are not supported by the evidence from research articles.

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References

Almario, C. V., Chey, W., Kaung, A., Whitman, C., Fuller, G., Reid, M.,… Martinez, B. (2015). Computer-generated vs. physician-documented history of present illness (HPI): Results of a blinded comparison. The American Journal of Gastroenterology, 110(1), 170-179. Web.

Carranza-Mamane, B., Havelock, J., Hemmings, R., Cheung, A., Sierra, S., Case, A.,… Vause, T. (2015). The management of uterine fibroids in women with otherwise unexplained infertility. Journal of Obstetrics and Gynaecology Canada, 37(3), 277-285. Web.

Clarke, C. (2014). Promoting the 6Cs of nursing in patient assessment. Nursing Standard, 28(44), 52-59. Web.

Kohtz, C., Brown, S. C., Williams, R., & O’Connor, P. A. (2017). Physical assessment techniques in nursing education: A replicated study. Journal of Nursing Education, 56(5), 287-291. Web.

Minen, M. T., Loder, E., Tishler, L., & Silbersweig, D. (2016). Migraine diagnosis and treatment: A knowledge and needs assessment among primary care providers. Cephalalgia, 36(4), 358-370. Web.

Moriarty, M., & Mallick-Searle, T. (2016). Diagnosis and treatment for chronic migraine. The Nurse Practitioner, 41(6), 18-32. Web.

Papaleontiou, M., & Cappola, A. R. (2016). Thyroid-stimulating hormone in the evaluation of subclinical hypothyroidism. JAMA: The Journal of the American Medical Association, 316(15), 1592-1593. Web.

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Papathanasiou, I. V., Kleisiaris, C. F., Fradelos, E. C., Kakou, K., & Kourkouta, L. (2014). Critical thinking: The development of an essential skill for nursing students. Acta Informatica Medica, 22(4), 283-286. Web.

Skeff, K. M. (2014). Reassessing the HPI: The chronology of present illness (CPI). Journal of General Internal Medicine, 29(1), 13-15. Web.

Vilos, G. A., Allaire, C., Laberge, P. Y., Leyland, N., Vilos, A. G., Murji, A., & Chen, I. (2015). The management of uterine leiomyomas. Journal of Obstetrics and Gynaecology Canada, 37(2), 157-178. Web.

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