Comprehensive Nursing History and Physical Assessment Guidelines

Chief Complaint and History of Present Illness

It is difficult to argue with the fact that any diagnosis is based on certain judgement of nurses and doctors. However, they follow certain guidelines for a complex and the most accurate identification of symptoms, causes, and conditions of a certain illness. An ability to assess a state of patient is primarily important to any nurse. That is why studying of medical history and physical assessment guidelines are compulsory elements of the nursery practice. Their activities include analysis of social, surgical, and medical history of a patient, as well as his/her relatives. Physical assessment guidelines presuppose a complex of examinations, which verify appropriateness of various functions of a human organism so that the basic functions, as well as entire system of a human organism, could be examined. Consequently, the following paper provides the entire comprehensive analysis of nursing history and physical assessment of a patient.

A patient is 21 years old male who complained about feeling of weakness, elevated hart rate, and low mental capacity after three months of playing in new local basketball team. The patient is a basketball player and he attends trainings three times per week. Every two weeks he participates in games. After every game, he feels extreme weakness and exhaust, which were not typical of him earlier. In other words, the patient becomes extremely tired even from such activity as a basketball game. The feelings of weakness and exhaust occur to the patient to various extents. As a result, he considers them to depend on how intensive the last game was. However, decreased mental capacity, as well as high heart beats, occurs to the patient during average days when he does not do any physical training and exercising. The patient is relatively anxious about his state as long as he dreams to become a professional basketball player. Consequently, he needs to be in a good physical shape for NBA draft.

To be more specific about chief complaints of the patient, the regular feelings of overall weakness and dryness in the mouth are admitted. In addition, the patient mentioned that he always feels a strong thirst even though he drinks enough water after a game or training. The patient did not confirm any sport-related traumas or being hospitalized after a game. Sometimes, such feelings occurred to the patient earlier when he was not playing for a new local basketball team. It is becoming increasingly apparent that the main cause of the problem is related to the patient’s sport activities, which is why a physical assessment is definitely needed. Regarding the above facts, the patient’s medical, surgical, and social issues have to be given an account in order to specify the causes of illness.

Past Medical, Surgical, and Social History

The patient did not mention any previous illnesses or diseases except average flu. Therefore, it is becoming increasingly apparent that the origin of the current illness of the patient is not based on complications of his previous diseases. However, probability of improper nursery intervention still exists as long as the patient did not confirm his reliance on medical services that were provided to him in the past. The patient seems to have a normal general health as long as any of specific conditions or disorders was not mentioned.

Surgical intervention, however, was admitted. The patient had a surgery on metacarpal ligament on his right hand two years ago. The patient claimed that a need for the surgery was not caused by his sport activity as long as a related trauma occurred in a domestic environment. At the same time, a probability of neglected surgery guideline can be noted. Nevertheless, the trauma has all signs of being originated from the patient’s primary occupation. The patient is right-handed, which is why he might have received some minor trauma while playing basketball. Then, that trauma worsened after some accident in a domestic environment, after which the patient consulted a doctor. In regards to social background of the patient, he was raised by his mother only. She works as an administrator in a local restaurant, while his elder sister works as a receptionist in a spa salon. The mother, as well as sister, does not have any specific conditions or disorders that may influence a general health of the patient. As for the patient’s father, he was also a professional sportsman and was known to play for local football teams. Thus, he might have experienced the same problem as his son so that a relation to sport activities is evident in this case.

Family History

The patient’s father was a professional sportsman, which creates an extremely high probability of a certain occupation-related disease. However, the patient’s father did not complaint about signs similar to complaints of the patient. Instead, hypertonia was diagnosed at the age of 43. That is why certain genetic perspective has to be included. Otherwise, the patient is tending to face the same health problems at the same age as his father did. The rest of the family medical history did not provide any specific data that can be used for a development of the patient’s diagnosis. The patient’s family, however, may have some diseases that are not identified yet, but the patient confirmed that none of his relatives has complaints concerning their health. Overall, a relation between the patient’s father and the patient can be traced as long as they are both sportsmen and the patient’s father might have faced the same problems.

List of Risk Factors

As long as a preliminary diagnosis has been not identified yet, three basic factors of a potential worsening of the patient’s state should be indicated. The most dangerous factor is hidden diabetes, which was not identified earlier. It may result in serious consequences as long as it may affect every aspect of the patient’s health. Still, such factor is less likely as long as it would be identified much earlier, especially in terms of the patient’s occupation. Thus, a case of latent diabetes is hardly possible. Instead, an evident lack of vitamins may worsen a state of the patient. He seems to lack certain substance in his organism due to his sports activities. Consequently, the overall vulnerability of the organism may result in infection. Such factor is especially dangerous for a sportsman, since excessive physical exercises weaken the organism. As a consequence, the patient is likely to become a vulnerable target for various bacteria agents with different periods of transmission and effect. That is why a distinct nutrition plan for the patient is required regardless of his preliminary diagnosis, since supplying the organism with the entire range of vitamins is always needed.

Needless to say, excessive physical exercising is the most dangerous factor for the patient as long as it may result in a dehydration, heart attack, etc. Hence, the patient is recommended to make a pause in his sports activities in order to prevent such serious consequences and determine a source of the problem because excessive playing basketball is assumed to be the driving force of the patient’s illness. In spite of the fact that a cause of the illness may be not related to the patient’s activities, he is required to avoid doing any physical exercises.

Review of Systems

To speak about review of the patient’s systems, certain abnormalities were detected in the following aspects. First of all, vascular system of the patient demonstrated low blood pressure and elevated heart rates. As a consequence, minor problems with breath were also observed. However, abnormalities in a vascular system are more significant, since blood pressure, as well as heart rate, occurred to be unnatural for such age and gender, especially with regard to the fact that the patient is almost a professional sportsman. A state of a patient’s vascular system can be considered as not completely satisfactory because it evidently does not comply with standard requirements to a general health of a sportsman. In addition, heart rate and blood pressure were measured in sitting, as well as standing positions, which showed a considerable difference. The patient did not complaint about pains in his heart so that the cause of the illness is not related to a poor heart performance.

The second abnormality was detected after urinal analysis. A color of urine, as well as its clarity, was not normal. The further lab analysis demonstrated a strong presence of ketones, glucose, and proteins. The patient confirmed that he did not consume any special medications for his sport performance. As a result, the increased levels of glucose and protein are caused by a certain absence of metabolic balance. As long as urine system has particular problems, deviations in metabolism can be assumed. First of all, absence of balance between intercellular and extracellular fluids may be present. The patient’s sympathetic neural system reacts on a certain internal irritation, which causes emission of glucose, ketones, and protein. In the same way, increased heart rate and low blood pressure are a reaction on a distinct internal factor of the patient’s organism.

Functional Assessment

As for functional assessment, numerous abnormalities were also identified. First of all, the patient occurred to produce insufficient urine. In addition, the patient admitted that he started sweating less in comparison with his previous experience in basketball team even though playing in a new team is substantially harder. The heart beats of the patient were also elevated, which helps identify an entire complex of internal problems. Such signs indicate an evident dysfunction of internal metabolism and dysfunction in balance of intercellular fluids in comparison with extracellular ones. Such dysfunction can be caused by various factors, which is why the assessment of the other functions is required. However, a fact that the patient drinks much water and still has a feeling of thirsts suggests an assumption that he suffers from a regular dehydration. Difference between extracellular and intracellular fluids can be explained by a lack of fluids in the organism.

Therefore, dehydration can be assumed to be the main cause of the patient’s illness. A case of dehydration is quite possible because consumption of fluids does not comply with factual supplies of water in the patient’s organism. Probability of such deviations in the patient’s metabolism is quite high, since his sport activity makes a significant impact on the internal functionality of his organism. Despite the fact that it is not a final decision regarding the case, a current functional analysis proves the diagnosis of dehydration throughout deviation in balance between extracellular and intercellular fluids. The rest of the patient’s systems were detected to function appropriately. It implies the evidence of abnormal metabolism itself as long as some other disorders are accompanied with specific symptoms, except changed metabolism. It is worth mentioning that proactive production of ketones, glucose, and protein implies the fact that metabolism was working improperly for a long period.

Nutrition Assessment

As a consequence, nutrition assessment detected a lack of fluids in daily meals of the patient. As a matter of fact, water is the only source of fluids for the patient. He consumes most of his water at training and during basketball matches so the organism does not receive any reserves of water. It can be explained by the fact that a regular fluid intake is utilized for processing standard metabolism during excessive physical exercising. Therefore, the patient suffers from weakness, thirst, and absence of sweat because his organism does not contain sufficient amounts of fluids.

Moreover, assessment of the patient’s nutrition indicated a frequent consumption of such unhealthy food as French fries, burgers, etc. Such type of food contains cholesterol that prevents vascular system from balanced blood cycling. In addition, cholesterol thwarts the kidneys from production of fluids, which is why insufficient intercellular, as well as extracellular fluids can be spotted in the patient’s organism. Nutrition is not the primary cause of the patient’s state, but absence of fluid food and a large presence of fast food in the patient’s nutrition are distinct intensifiers of metabolic dysfunction. Thus, nutrition plan of the patient should be changed.

The patient needs to include some fluids in his daily meals, as well as fruits and vegetables in order to leverage cholesterol within his organism. Food, which contains glucose and proteins, is also not recommended for a particular period, since such substances are already excessively present. Instead, the patient is required to include some Omega-based food. It is necessary to mention that any Omega-based substances, except those, which include Omega-7 acid, will create favorable conditions for the patient’s metabolism. The organism needs to restore the balance between extracellular and intercellular fluids. Consequently, the supplying of organism with various fluid substances is essential.

Physical Examination

Physical examination of the patient proved a regular dehydration of the organism. Identification of mouth sores, as well as the entire throat, demonstrated an evident lack of internal fluids. The patient confirmed that such state was observed within three past months with different degrees of soreness. At the same time, examination of the patient’s extremities also proved a presence of a strong dehydration. Extremities were cold, which is caused by the insufficient blood cycling. As a consequence, vascular system is working inappropriately due to increased cholesterol and glucose. Therefore, the organism lacks fluids to neutralize effects of such substances. In addition, a strong presence of junk food in the patient’s nutrition made its impacts and resulted in intensive production of cholesterol. Such signs are a distinct evidence of dehydration as a result of excessive physical exercising and improper metabolism of the patient.

In a similar way, problems with breath were identified. In fact, the patient’s excessive extracellular fluids are present as long as he admitted difficulties with breath during trainings and games. However, amounts of the extracellular liquids are not substantial so it was relatively difficult for the patient to play basketball. Besides that, elevated pulse and heart rate are also signs of dehydration, since the patient’s kidneys are not able to produce more blood for a normal cycling. Thus, the same portions of blood are pumped within the patient’s vascular system. The patient also mentioned lowered mental capacity that can be explained by a reaction of sympathetic neural system. The current system serves a function of reacting on stresses. Hence, such reaction is quite justified as dehydration is an obvious stress for the entire organism. However, such reaction is not extremely strong and further complications can be prevented with nursery intervention.

The rest of physical examination did not report about any abnormalities, which is why a preliminary diagnosis of a prolonged dehydration can be observed. It is necessary to admit a large health capacity of the patient, since dehydration produces its effects within a shorter time span. Thus, the patient needs to leverage his internal fluids and establish a normal metabolism. In addition, proactive supply of the organism with fluids can also be needed as the patient does not consume much liquid on a day-to-day basis. Physical examination detected a strong dehydration of the organism, but a profound nursery intervention may not be required. That is why the patient should undergo a complex of procedures for leveraging the internal fluids and supplying the organism with water. Provided that the patient’s state does not improve, in-depth nursery intervention will be necessary as metabolism should be entirely established. Otherwise, certain complications may occur.

Conclusion and Recommendations

It is appropriate to make a general comment on the fact that the patient is evidently having a strong dehydration. A disorder was caused by a low level of liquids, regular excessive physical exercising, and absence of liquids in a daily nutrition of the patient. Moreover, the patient’s father was also a sportsman so certain genetic influences can also be observed. The patient complained about feeling of weakness, low mental capacity, constant feeling of thirst, and inability to sweat even though he attends training three times per week. Taken together, such factors led to a strong dehydration that was not explicit to the patient. He continued attending trainings and basketball games for almost three months until the described feelings intensified. Consequently, dehydration is an obvious diagnosis because none of the other disorders were identified within the examination period.

The patient is having an inappropriate metabolism due to the absence of balance between extracellular, as well as intercellular fluids, which increased production of ketones, glucose, and proteins. A large presence of unhealthy food in the patient’s nutrition led to a proactive growing of cholesterol, which in combination with ketones thwarts the patient’s kidneys from a production of blood cells resulting in the fact that the vascular system pumps the same portions of blood. As a result, the patient was having elevated heart rate and pulse with low blood pressure. Likewise, problems with breath also occurred due to the excessive level of extracellular liquids. Low mental capacity of the patient can be explained by a reaction of sympathetic neural system that sends signals about internal stress. The patient was prescribed liquid-based nutrition. New nutrition also includes Omega-based substances (except Omega-7) in order to establish a normal metabolism of the patient.

Therefore, the patient has to leverage internal liquids throughout optimized nutrition and substantial consumption of liquids. In case non-nursery intervention occurs to be ineffective, the patient will need to pass a complex of IV injections of liquids and certain medication treatment depending on the level of ketones, glucose, protein, and cholesterol in his organism. Moreover, any physical exercising is strongly prohibited at least for three weeks as the organism needs to restore its normal metabolism. The patient needs an overall rest as long as his neural system was under a stress for quite a long period. Provided that the state of the patient does not improve, the patient will have to undergo a profound treatment at the hospital. It is caused by the fact that worsened metabolism implies multiple consequences that should be forecasted and prevented on time. Finally, the patient is recommended to consume more liquids and avoid any food that contains cholesterol.