PORTFOLIO OF HEALTH ASSESSMENT

COLLEGE OF NURSING ,SIMS, SERVICES HOSPITAL LAHORE.

INTRODUCTION

Name:
Roll no.
Subject: Health Assessment
Subject Teacher:
 Table of Content
Content Page no. Remarks

 Acknowledgement Case 2
Case 1  Disease 2
 Disease 1 (GERD) (varicose vein)
 Pathophysiology  Pathophysiology
 Causes  Causes
 Clinical manifestation  Clinical
 complication manifestation
 Management  Complication
 Medical  Management
 Surgical •Medical
 nursing •Surgical
 Patient profile •nursing
 Patient history  Patient profile
 Assessment by:  Patient history
 Gordon’s pattern  Assessment by:
 Head to toe •Gordon’s pattern
assessment •Head to toe
 Nursing diagnose assessment
 Nursing care plan  Nursing diagnose
 Nursing care plan

Acknowledgment
I student of BSc Generic Nursing (2ndyear)Bow my head before ALLAH
ALMIGHTY in the gratitude of giving me opportunity for this case study.

I am thankful to Mam Asma Taj our worthy principal for providing us such great
platform to study well ,a healthy educational environment.

I would like to express my respect and gratitude to my subject teacher,

Who has given me support and cooperation and also time to time feedback in
completing my case study.

Regards:
CASE STUDY 1

Gastro Esophageal Reflux Disease

Introduction:

Gastro esophageal Reflux disease is a fairly common disorder marked by the

backflow of gastric or duodenal contents into the esophagus that causes
troublesome symptoms and mucosal injury to the esophagus.

Causes:
Excessive reflux may occur because of

 An incompetent lower esophageal sphincter

 Pyloric stenosis
 Hiatal hernia
 Motility Disorder
 GERD is associated with tobacco use , coffee drinking, alcohol
consumption ,gastric infection with HELICOBACTER PYLORI.

Clinical Manifestations:
 Pyrosis
 Regurgitation
 Dyspepsia and Dysphagia
 Hyper salivation

Complications:
When left untreated, GERD can lead to complications, including:

• Adult onset Asthma.

• Esophagitis.

• Stricture (narrowing of the esophagus).

• Regurgitation of acid into the lungs.

• Sinusitis.

Prevention:
Try to;

• Maintain a healthy weight

• Stop smoking

• Elevate the head of bed

• Start on your left side

• Don not lay down after a meal

• Eat food slowly and chew thoroughly

• Avoid foods and drinks that trigger reflux

• Avoid tight- fitting clothing

Medical and Surgical Management:

 Reflux Inhibitors like Bathanechol Chloride are used to treat GERD.
 Histamine-2 receptor antagonists (Famotidine, cimetidine) also used for
this purpose.
Surgical management involves:
 Laparoscopic Nissen fundoplication.

Nursing Management:
 Nursing management involves:
 Educate patient to avoid situations that decrease lower esophageal
sphincter
 Tobacco cessation
 Limiting alcohol
 Elevating head of the bed
 Avoiding eating before bed
 Altering the diet
 Weight lose

Patient Profile
Ward/Unit: Medical unit 1
Patient’s name: Arslan Ali

Father’s name: Maqsood Ali

Age: 35 years

Sex Male

Religion: Islam

Bed no.: 5

Date of admission: 10 October 2022

Occupation: Hotel manager

Language: Punjabi

Education: B.A

Marital status: Married

No. of Children: 03

Medical diagnosis: GERD

Patient History
Chief complaint:
 Heart burn
 Chest pain
 Difficulty in eating
  Backflow of gastric content

Past medical history:

 No past medical history

Family history:
 Family history of diabetes
Allergies :
 Not known

Occupation:
 Hotel manager

Socio economic status:

 Low socio economic status

GORDON’S HEALTH PATTERN

 1. Health perception and health management:
Q.1 How has the general heath been?
Patient verbalized that he does not get ill all the time , when he was young but
due to his old age he get infected very soon. Generally, now a days he can not
handle his health issues.

Q.2 What is the health in your perception?

Health in the perception of patient is being ok without any pain or weakness.

Q.3 How much you give importance to your health?

Patient verbalized that I belong to a middle class family so I have not much
resources to care my health or not enough time to care myself.

Q.4 whenever you get ill you go to hospital or manage it yourself at home?

Patient verbalized that; with minor illness he does not visit hospital.in case of any
severe pain he goes to nearby clinics.

Q.5 do you follow doctor’s prescription or use advised medicine only when
needed?

Patient verbalized that he does not follow prescription as advised ,only use
medicines when he needs.

Q.6 Self examination/ routine wise baselines/labs per repeatedly or only when
get ill?

Patient verbalized that he does self examination or labs only when get ill.

2. Nutrition and Metabolic pattern:

Q.1 What do you eat? likes and dislikes?

Patient verbalized that he eat simple food. He likes spicy and dislike sweets.

Q.2 how many meals you eat daily?

Patient verbalized he eat three meals a day. Breatfast ,lunch and dinner.
Q.3 Do you eat full nutrition food or prefer junk foods?

He verbalized that I like to eat fruits but I can not eat vegetables happily.he does
not like junk food.

Q.4 Do you feel stomach or abdominal discomfort after having your meals?

Patient states that he feels stomach pain and heart burn after having meal.

Q.5 How you gain or loss your weight in last 2 months?

Patient weight is gradually decreasing from last two months.

Q.6 Have you any skin problems? Dryness ? dental problems ?

Patient’s skin is pale , dry and wrinkled. He has no dental issue.

3. Elimination pattern:
Q.1 What is bowel elimination frequency? Do you feel any discomfort or pain
while voiding? Do you use laxatives?

Patient states that he defecates one time a day. while defecation he does not feel
any discomfort and also does not use any lexatives.

Q.2 What is your urine elimination frequency? Any discomfort while voiding

Patient’s urination frequency is 1000 ml per 24 hours.

He verbalized that he has burning sensation while voiding.

Q.3 Excess of perspiration? Odor perspiration?

No excessive perspiration or odor in perspiration.

4. Activity and exercise pattern:

Q.1 Do you have sufficient energy for desired or required activity?
Patient states that he has no energy to even walk .

Q.2 What is your exercise pattern? its type ? its regularity?

Patient has no routine for any type of exercise.

Q.3 What do you do in spare time activities?

Patient does goucips with friends in spare time.

5. Sleep and rest pattern:

Q.1 How many hours you sleep daily?

Patient usually sleeps 6 hours daily.

Q.2 How many naps you take daily?

Patient due to his disease condition, can not sleep adequately but takes small
naps like four to five naps per 24 hours.

Q.3 Do you have sleep onset problems? Aids?

Patient is unable to sleep well. But he does not use sleeping pills.

6. Cognitive perceptual pattern:

Q.1 Do you have hearing difficulty?

Patient does not use any hearing aids.

Q.2 What is your vision status? do you wea4 glasses ?

Patient’s vision is weak but he does not wear glasses.

Q.3 Any changes in memory daily ?

Due to aging process , there are changes in daily memory.

Q.4 Are you easy or feel difficulty to make decisions?

Patient has no difficulty in making decisions.

7. Self – perception / self – concept pattern:
Q.1 How would you describe yourself ?

Patient describe him as a middle class and working in an hotel.

Q.2 Which changes occur in your body in these days ? are these causing
problems for you?

Weakness , paller, epigastric pain , heart burn, weight loss has made me upset.

Q.3 What type of changes you feel about your self ?

Patient now a day suffering from aging , getting older, making him unable to be
active as like he was in his past.

Q.4 Which situations make you angry ?

Patient verbalized people’s misbehavior always made me angry.

Q.5 Have you ever lost hope or thought that you cannot do any thing?

Patient is now in state of stress of getting never healthy like he was in previous
state of health.

8. Role and Relationship pattern:

Q.1 Are you living alone or with family ?

Patient is living in a joint family.

Q.2 What is your role in family structure ?

Patient has strong and leading role in his family structure.

Q.3 Do you have major role in family deci:sions?

Patient verbalized yes, my family obeys me and my decisions.

Q.4 Do you think your family depends upon you for their daily affairs ?

Patient is senior most person in his family , so he has much important role in his
family.

Q.5 How do family respond on your illness?

Patient verbalized that my family give value to my illness and take me to hospital
whenever I gets ill.

9. Coping Stress Tolerance pattern:

Q.1 What type of big changes or crisis occur in your life ?

Yes, patient’s wife has died recently.

Q.2 What helps you more in coping any stress or greif?

Patient verbalized that my family support is big relief for me.

Q.3 Do you tense most of time and take problems seriously ?

Patient verbalized yes, I remain tense a lot of times and take problems seriously.

10. Reproductive / Sexuality pattern :

Q.1 Are secondary sex characteristics fully developed at proper age ?

Patient verbalized yes, secondary sex characteristics are fully developed when I
was 15 years old.

Q.2 How many children you have ?

Patient verbalized that , I have three children . one daughter and two sons.

11. Values and Belief pattern:

Q.1 Do you think values are important in our daily life ?
Patient verbalized that , yes values and ethics are important in our daily life.

Q.2 Do you follow all values set by your religion and society?

Patient verbalized yes, I do follow all values set by our religion and society.

Q.3 Do you think that religion is at most priority?

Patient verbalized yes, I have strong believe on my religion and put it at most
priority.

Q.4 Can you do anything for your religion?

Patient can ever die for his religion.

Nursing diagnosis
 Acute pain related to acid reflux secondary to GERD.
 Risk for aspiration related to esophageal disease affecting the lower
esophageal sphincter.
 Anxiety related to change in health status of the patient as evidence by
increased fear.
 Nausea related to irritation of gastric mucosa as evidence by gagging
sensation.
 Knowledge deficit related to self care.
Nursing care plan
Case Study 2
VARICOSE VEIN

Varicose vein
DEFINITION:
Varicose veins (varicosities) are abnormally dilated, tortuous, superficial veins
caused by incompetent venous valve.

Most commonly, this condition occurs in the lowers extremities, the saphenous
veins, or the lower trunk ,but it can occur elsewhere in the body , such as the
esophagus .

Pathophysiology:
Varicose veins may be primary (without involvement) or secondary (resulting
from obstruction of deep veins).

A reflux of venous blood results in venous stasis. if only the superficial vein are
affected, the person may have no symptoms but may be concerned by the
appearance of the veins.

Causes :
Varicose veins often affect the legs. The veins there the farthest from your heart,
and gravity makes it harder for the blood to flow upward.

Some potential causes for the varicose veins include:

 Pregnancy
 Menopause
 Age over 50
 Standing for long periods of time
 Obesity
 Family history of varicose veins

CLINICAL MANIFESTATIONS:
 Dull aches
 Muscle cramps
  Increased muscle fatigue in lower legs
 Ankle edema
 Nocturnal cramps
 Pain and pigmentation

Assessment and diagnostic studies:

Diagnostic tests for varicose veins include:

 Duplex ultrasound scan

 X- ray studies
 CT venography

Medical and surgical management :

 Compression therapy is the most conservative treatment
option .compression stockings are design to apply specific pressure to the
legs to alleviate discomfort and swelling and do not require a prescription.
 Topical arnica comes in cream ( or gel ointment) that can be applied to the
skin overlying inflamed or painful varicose veins.
 Herbal remedies
 Choose non restrictive clothing

Surgical treatment:
 Thermal ablation
 Microphlebectomy
 Sclerotherapy
 Ligation and stripping

Nursing management:
  The patient is advised to maintain compression on the on the affected limbs
for at least 24 hours and then wear compression stockings while
ambulatory for 1 week post procedure
 The patient advised to restrict strenuous exercise, such as weight lifting ,
bicycle riding or swimming for 2 weeks.
 The patient is informed that bruising may occur along the course of a
saphenous vein .
 NSAID’s medications such as ibuprofen and cool compresses are used as
needed.
 Promoting comfort
 Understanding patients
 Promoting home, community based and transitional care.

Patient Profile
Ward/Unit: Surgical unit 4

Patient’s name : Ali Raza

Father’s name: Ashraf

Age: 40years

Sex: Male

Religion: Islam

Bed no. : 10

Date of admission: 10 august 2022

Occupation : Traffic Police

Language: Punjabi

Education: F.A

Marital status: Married

Number of Children: 01

Medical diagnosis: Varicose vein

Chief complaint:
 Lower leg pain
  Difficulty in standing
 Bulging of veins

Past medical history:

 No past medical history

Family history:
 Family history of hypertension

Allergies:
 Not known

Occupation:
 Traffic policeman

Socio economic status:

 Low socio economic status

GORDON’S HEALTH PATTERN

1.Health perception and health management:
Q.1 How has the general heath been?
Patient verbalized that he does not get ill all the time , when he was young but
due to his old age he get infected very soon. Generally now a days he can not
handle his health issues.

Q.2 What is the health in your perception?

Health in the perception of patient is being ok without any pain or weakness.

Q.3 How much you give importance to your health?

Patient verbalized that I belong to a middle class family so I have not much
resources to care my health or not enough time to care myself.

Q.4 Whenever you get ill you go to hospital or manage it yourself at home?

Patient verbalized that with minor illness he does not visit hospital.in case of any
severe pain she goes to nearby clinics.

Q.5 do you follow doctor’s prescription or use advised medicine only when
needed?

Patient verbalized that; he does not follow prescription as advised ,only use
medicines when he needs.

Q.6 Self examination/ routine wise baselines/labs per repeatedly or only when
get ill?

Patient verbalized that he does self examination or labs only when get ill.

2. Nutrition and Metabolic pattern

Q.1 What do you eat? likes and dislikes?

Patient verbalized that he eats simple food. He does not like spicy food.

Q.2 how many meals you eat daily?

Patient verbalized he eat three meals a day. Breatfast ,lunch and dinner.
Q.3 Do you eat full nutrition food or prefer junk foods?

He verbalized that I like to eat fruits but I can not eat vegetables happily.he does
not like junk food.

Q.4 Do you feel stomach or abdominal discomfort after having your meals?

Patient states that he does not feels any stomach pain and heart burn after
having meal.

Q.5 How you gain or loss your weight in last 2 months?

Patient weight is gradually decreasing from last two months.

Q.6 Have you any skin problems? Dryness ? dental problems ?

Patient’s skin is pale , dry and wrinkled.

3. Elimination pattern
Q.1 What is bowel elimination frequency? Do you feel any discomfort or pain
while voiding? Do you use laxatives?

Patient states that he defecates one time a day.while defecation he does not feel
any discomfort and also does not use any laxatives.

Q.2 What is your urine elimination frequency? Any discomfort while voiding

Patient’s urination frequency is 1000 ml per 24 hours.

He verbalized that he has no difficulty in voiding.

Q.3 Excess of perspiration? Odor perspiration?

No excessive perspiration or odor in perspiration.

4. Activity and exercise pattern

Q.1 Do you have sufficient energy for desired or required activity?
Patient states that he has no energy to even walk .

Q.2 What is your exercise pattern ? its type ? its regularity?

Patient has no routine for any type of exercise.

Q.3 What do you do in spare time activities?

Patient reads books in his spare time.

5. Sleep and rest pattern:

Q.1 How many hours you sleep daily?

Patient usually sleeps 6 hours daily.

Q.2 How many naps you take daily?

Patient takes small naps like four to five naps per 24 hours.

Q.3 Do you have sleep onset problems? Aids?

Patient is unable to sleep well. But he does not use sleeping pills.

6. Cognitive perceptual pattern:

Q.1 Do you have hearing difficulty?

Patient does not use any hearing aids.

Q.2 What is your vision status? do you wea4 glasses ?

Patient’s vision is weak but he does not wear glasses.

Q.3 Any changes in memory daily ?

Due to aging process , there are changes in daily memory.

Q.4 Are you easy or feel difficulty to make decisions?

Patient has no difficulty in making decisions.

7. Self – perception / self – concept pattern:
Q.1 How would you describe yourself ?

Patient describe him as a middle class and elder of his family.

Q.2 Which changes occur in your body in these days ? are these causing
problems for you?

Weakness ,malaise,heaviness in legs,difficulty in standing and walking,weight loss

has made me upset.

Q.3 What type of changes you feel about your self ?

Patient now a day suffering from aging , getting older, making him unable to be
active as like he was in his past.

Q.4 Which situations make you angry ?

Patient verbalized people’s misbehavior always made me angry.

Q.5 Have you ever lost hope or thought that you can not do any thing?

Patient is now in state of stress of getting never healthy like he was in previous
state of health.

8. Role and Relationship pattern:

Q.1 Are you living alone or with family ?

Patient is living in a joint family.

Q.2 What is your role in family structure ?

Patient has strong and leading role in his family structure.

Q.3 Do you have major role in family decisions?

Patient verbalized yes, my family obeys me and my decisions.

Q.4 Do you think your family depends upon you for their daily affairs ?

Patient is senior most person in his family , so he has much important role in his
family.

Q.5 How do family respond on your illness?

Patient verbalized that my family give value to my illness and take me to hospital
whenever I gets ill.

9. Coping Stress Tolerance pattern:

Q.1 What type of big changes or crisis occur in your life ?

Yes patient’s wife has died recently.

Q.2 What helps you more in coping any stress or greif?

Patient verbalized that my family support is big relief for me.

Q.3 Do you tense most of time and take problems seriously ?

Patient verbalized yes, I remain tense a lot of times and take problems seriously.

10. Reproductive / Sexuality pattern :

Q.1 Are secondary sex characteristics fully developed at proper age ?

Patient verbalized yes, secondary sex characteristics are fully developed when I
was 15 years old.

Q.2 How many children you have ?

Patient verbalized that , I have a son.

11. Values and Belief pattern:

Q.1 Do you think values are important in our daily life ?
Patient verbalized that , yes values and ethics are important in our daily life.

Q.2 Do you follow all values set by your religion and society?

Patient verbalized yes, I do follow all values set by our religion and society.

Q.3 Do you think that religion is at most priority?

Patient verbalized yes, I have strong believe on my religion and put it at most
priority.

Q.4 Can you do anything for your religion?

Patient can ever die for his religion.

Nursing Diagnosis:
 Acute pain related to tissue ischemia.
 Impaired skin integrity related to vascular insufficiency.
 Impaired physical mobility related to activity limitation due to pain.
 Risk for infection related to imbalance nutritional status.
 Disturbed body image related to varicose vein.
 Deficit knowledge related to disease and health care.
Nursing Care Plan