Holistic Patient Assessment: Client Q

Part 1

Client Q is a 25 years old lady who is my immediate neighbor. After speaking to her about my desire to use her to perform a holistic patient assessment, she agreed and all I had to do is to begin the procedure which included collecting health history and performing all the necessary assessments including physiological, psychological, and developmental assessment among others (Clarke, Roscoe, Appleton, Dale, & Nanton, 2019).

Health History

            I began by asking the patient to tell me about her health history. The patient reported that she has never been admitted to the hospital for a medical condition. However, she has been admitted in the gynecological unit twice due to heavy menstrual bleeding. The first time of admission to the gynecological unit took place when she was nineteen years while the second admission occurred at the age of twenty-three. At each, she had been managed appropriately before being discharged, and the gynecological conditions disorders did not affect her first pregnancy. Besides, the client reported that she had never been admitted to the surgical unit due to a surgical operation. Concerning family medical history, the client that her father suffers from diabetes mellitus which also affected her grandfather. Other medical conditions are not evident in the family. Regarding the family planning method that she uses, client Q told me that her doctor recommended using progesterone-only pills since other methods could increase chances of heavy menses.

Physiological Assessment

            In the physiological assessment, I examined the client’s external and internal body performance (Considine, Trotter, & Currey, 2016). Starting from the respiratory system, the client was bleeding normally. However, I noticed some nasal discharge which comprised of heavy mucus. Her voice was also hoarse. Secondly, I assessed the cardiovascular system by measuring client Q’s heart rate and blood pressure. Heart rate was 72 beats/minute while blood pressure comprised of systolic pressure of 124mmHg and a diastolic pressure of 78 mmHg. The patient also had a well-functioning excretory system. Lastly, I assessed the external body parts to determine their functioning. Her legs were stables such that she could walk on her own. Besides, her hands were also functioning as usual.

Psychological Assessment

            I applied several psychological tests including the use of questionnaires and attitude tests and personality tests to determine her psychological wellbeing (Ikkos, Gall, & Smyth, 2018). I asked questionnaires that matched her level of education, and she managed to eight out of ten of the asked questions. More so, I subjected her to a personality test which involved the use of free response measure. Free response measures allow individuals to answer questions based on their innate feelings and personality. As such, they can be used to analyze people’s behaviors so that their personalities can be detected. Lastly, I performed an attitude test to client Q to determine her perceptions and preferences of the around her.

Social Assessment

            In healthcare, social assessment refers to the assessment of patients’ health in relation to their social lives (Ikkos, G., Gall, & Smyth, 2018). Therefore, I had to assess the client’s social history. Firstly, I asked the client about her occupation which she responded that she is a teacher. She does not abuse any drugs, including alcohol, tobacco and other illicit drugs. The patients reported that she rarely engages in healthy exercises except walking and performing house chores. Besides, I asked her about her sexual preferences, and she responded that she believes in marriage since she already married with one child.

Cultural Assessment

            Cultural assessment involves the assessment of the patient’s cultural values and beliefs (Jeffreys, 2015). According to client Q’s culture, patients should not rely much on hospitals in case of sickness. Client Q beliefs that some sickness, such as mental illnesses results due to cultural and social reasons. For example, she claims that most mental illnesses result due to witchcraft. Besides, the client claimed that in her culture, women are not allowed to eat eggs during pregnancy. Also, eating pork is prohibited for all people in her culture. Therefore, she has to depend on other food instead of going against her cultural beliefs.

Developmental Assessment

Developmental assessment involves assessing the clients’ developmental milestones to determine any delayed or skipped milestones. I assessed the client’s speech, language, and motor skills and she exposed good functioning in them. Besides, she showed no signs of personality impairment such that remembers all the events she has gone through in her life. This shows that client Q went through all her developmental milestones successfully.

Spiritual Assessment

            Spiritual assessment in healthcare refers to the assessment of patients’ religious beliefs in relation to the healthcare process (Hodge, 2015). Client Q is a devoted Christian who believes that God can bring healing even when medical care fails. More so, she believes that anything that happens in her life is due to God’s plan. Thus, all the diseases that she suffers from are brought by God as a temptation so as to test her faith. Also, client Q reported that she prays every time to God so that he can help her heal from incoming diseases. All of her family members are devoted Christians as well.

Part 2

Interpretation of Findings of the Holistic Patient Assessment

On doing a physiological assessment of client Q, I realized that she had been diagnosed twice of excessive menstrual bleeding which is called menorrhagia. There are several pathophysiologic reasons leading to menorrhagia. First of all, anatomic causes, which may include foreign growths in the uterus may cause unusual heavy bleeding (Hapangama, & Bulmer, 2016). Such growths include tumors and lesions among others. Secondly, menorrhagia may result due to bleeding problems which result from platelet disorders. For instance, deficiency of platelets and fibrin can cause heavy menstrual bleeding. Lastly, people with organic diseases such as renal failure have a high risk of experiencing heavy menstrual flow. In this case, they will have some gonadal resistance to hormones which will result in menstrual irregularities, including menorrhagia. Therefore, client Q might have had one of the pathophysiological problems discussed above.

On a holistic basis, the client’s episodes of menorrhagia can be assessed based on the different areas of her normal life. Firstly, the condition will affect her physiological functioning such as the inability to engage in sex with her spouse. As such, the client’s psychological aspect will also be affected. For instance, client Q will develop a psychological disturbance due to heavy menses which affects her daily activities. Furthermore, the client will be affected socially such that she will not be in a position to engage in social activities such as exercising among others. More so, the intense menstrual bleeding may have an impact on her cultural beliefs and values. For example, she may think that the recurrent menorrhagia is due to witchcraft. Developmental assessment is also necessary as it helps to determine any abnormal development in her reproductive organs that may result in the disorder. Lastly, spiritual assessment is as well important to determine her spiritual thinking about her condition.

Since recurrent menorrhagia has a negative impact on the client’s life such as recurrent stress, engaging her in coping skills is crucial for her wellbeing. In this case, client Q should be informed that heavy menstrual bleeding is a condition which can be managed in the hospital so that she can develop a tendency to go for checkups when signs of menorrhagia start showing. In this regard, she will avoid stress related to the condition. Treating the client is the best way to solve her stress since she will turn out to be healthy and willing to engage in daily activities. However, health care workers should apply a holistic management plan which involves managing all areas of the client’s condition. This includes physiological, psychological, cultural, social, and spiritual management.

Part 3

Teaching Plan

            A teaching plan is essential as it enables health care workers to manage all the required areas of management holistically. First of all, the goal of the teaching plan in physiological management is to ensure that the client recovers from heavy menstrual bleeding. Secondly, the teaching plan will enable nurses to manage psychological stress. In this case, nurses will plan on how to address the psychological issue affecting the client. Thirdly, health care personnel will apply the teaching plan the social aspects of the patient’s wellness by teaching her to engage in social activities with the family and others to impact her wellness. Concerning cultural aspects of the patient’s life, nurses will try to counsel the client about beliefs and value that undermine her attitude to seek medical care. Since spirituality is embedded in everyone’s life, health care personnel should encourage the patient to keep trusting in her faith to promote positive recovery.  Lastly, the management of the developmental aspects will involve teaching her how developmental milestones impacted her acquisition of the disease.

As such, I will teach the patient to impact on each of the goals. For example, I will teach her to visit the hospital in case she observes physiological changes in her menstrual cycle. At the hospital, holistic assessment and management of the condition will be done. Evaluation of teaching will be based on how the patient has understood the concepts. Thus, I will request her to restate my teachings.

Reference

Clarke, A. L., Roscoe, J., Appleton, R., Dale, J., & Nanton, V. (2019). “My gut feeling is we could do more…” a qualitative study exploring staff and patient perspectives before and after the implementation of an online prostate cancer-specific holistic needs assessment. BMC health services research, 19(1), 115.

Considine, J., Trotter, C., & Currey, J. (2016). Nurses’ documentation of physiological observations in three acute care settings. Journal of clinical nursing, 25(1-2), 134-143.

Hapangama, D. K., & Bulmer, J. N. (2016). Pathophysiology of heavy menstrual bleeding. Women’s Health, 12(1), 3-13.

Hodge, D. R. (2015). Spiritual assessment in social work and mental health practice. Columbia University Press.

Ikkos, G., Gall, A., & Smyth, C. (2018). The Stanmore Nursing Assessment of Psychological Status (SNAPS): not just for spinal cord injury rehabilitation?.

Jeffreys, M. R. (2015). Teaching cultural competence in nursing and health care: Inquiry, action, and innovation. Springer Publishing Company.