ADVANCED NURSING PRACTICE FIELD EXPERIENCE-TASK 2 1 ADVANCED NURSING PRACTICE FIELD EXPERIENCE-Task 2 Sabrina Williams Western Governors University Advanced Nursing Practice and Field Experience UNT2 Brandy Faker, RN BSN & Kimberly Richards, RN MSN MBA June 30, 2014
ADVANCED NURSING PRACTICE FIELD EXPERIENCE-TASK 2 2 ADVANCED NURSING PRACTICE FIELD EXPERIENCE-Task 2 D. Analyze the primary findings of the comprehensive health assessment you preformed. PW is a thirty-five year old Caucasian gentleman that appears to be his stated age; he came in today for general check up. He has no known drug allergies and is currently taking three over-the-counter medications; generic Prilosec, generic Claritin and a multivitamin that he takes daily. He has a medical history of Kyphosis as a child with surgical intervention of a Kyphoplasty at the age of fifteen. As and an adult, he suffers from back pain related to his Kyphoplasty, acid reflux and environmental allergies. He obtained his flu vaccine this past flu season and believes his tetanus vaccination is current, but is unsure of the date. He has a family history of hypertension and Kyphosis with his father, depression with his mother, no medical issues with his brothers and lupus with his grandmother. PW’s social history is as follows: he passed a kidney stone on his own with no surgical intervention and drinks occasionally. He was born in Wenatchee, Washington. While in school he obtained his GED and Associates Degree in Accounting. He currently works as a warehouse supervisor. PW has been married for nine years and has two children, boys, ages 7 and 5. His interest/hobbies include video games and anything to do with the NFL. Review of Symptoms General - About ten years ago PW had a twenty-five pound weight loss as a result from a change in his diet. Skin - At times he has bilateral upper arm eczema. He is not currently experiencing symptoms and denies ever using any treatment. Head - He gets lightheaded occasionally and when he does he finds something to eat and it resolves. Eyes - His last vision check was one year ago. His optometrist said his vision is 20/16. Throat - This past April was
ADVANCED NURSING PRACTICE FIELD EXPERIENCE-TASK 2 3 his last dental exam, in which they preformed a bridge. Cardiac - He occasionally has heart palpitations when lying down, which resolve without intervention. G/I - He experiences heartburn/acid reflux that he takes medication daily to control. His last bowel movement was 06/17/2014. Urinary - PW feels that he has a “small bladder” with hesitancy and dribbling, but has a strong stream. G/U (general) - He had a vasectomy in the past with no decrease in function. Musculoskeletal - He has back pain from his Kyphoplasty. Neuro - At times he has arms that feel like they’ve fallen asleep, bilaterally. This occurs while sitting with his arms resting on the arms of the chairs, lasting up to one minute at a time. Heme - He had four units of blood during this Kyphoplasty. Endo – He “runs hot” while he sleeps, and uses a fan. PW wears medium size gloves and shoes size 9.5.
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