Health Assessment essay



The client has lost the ability to make decisions by himself makinghis mother the primary caregiver. He identifies the need to havepeace since he has been fighting all his life because of thecondition. The statement is an illustration of the patient havingsubdued the decision-making capacity to his a family member (McMahan,Knight, Fried, &amp Sudore, 2013). The mother has been given themandate of making decisions on behalf of him. However, ethical issuesare imminent in the case based on how he is being treated by themother. An assessment of the patient illustrates that he is notefficiently taken care of by the mother. She fails to support him,and the client indicates that he is giving up. Despite having giventhe responsibility to the mother, she is not acting in the mannerthat is expected of her. It is unethical that she fails to adhere toher moral obligation of taking care of the patient.

Further, there is the legal aspect of the mother failing to takeresponsibility of looking after the son. The statement presented bythe client indicates that the mother is a surrogate decision-maker.The physician has the mandate of consulting with the mother since sheis the identified decision-maker for the patient. However, she can besued for failing in her duties as the client’s situation is worse.She leaves Reed at home exposing him to significant health risks. Theinjury of the left ankle occurred because he was going to helphimself to the bathroom. It is unfortunate that the client has todeal with the problems affecting him despite the mother having theadvance directives to tender for him.

Modificationsto the Physical Exam that may be needed based on Client Limitations

The case scenario presented negates a change in the physicalexamination to accommodate the constraints of the client. It ismandatory to consider having the patient go for screening on the leftankle. The fall may have resulted in a detrimental damage to thebones in the leg. A change in the approach of the physical exam makesit possible to determine the extent of injury to the patient’s leg.Further, the patient has been determined to have lost interest intaking drugs. An assessment could entail checking on the effects ofhaving abandoned the intake of drugs (Ball, Dains, Flynn, Solomon, &ampStewart, 2014). Also, there is the aspect of the patient spending abetter part of his time in the wheelchair. It could be crucial toconducting an assessment to determine the effect of the same as a wayof coming up with interventions that address the problem. Also, itcould be crucial to modify the physical exam to assess the extent ofecchymosis (Estes, 2013). The subcutaneous spot could be the resultof other conditions. A thorough analysis of the spot to determineunderlying factors could be essential since it may provideinformation regarding the availability or absence of a skin problem(Bogunovic, L., Gelberman, Goldfarb, Boyer, &amp Calfee, 2013).Also, an assessment of shortness of breath should be followed by ananalysis of other factors that could be causing the same. The patientcould be having a problem with the chest negating the need to developa physical exam that provides information on the condition. A changein the modification of the physical exam should provide moreinformation on the same.

PotentialHealthcare Referral needs for the Client

The potential referrals that could be appropriate for the patient areHospice and Florida Department of Children and Family. Hospice hasbeen identified as being suitable for patients who may be facing alife-limiting illness or injury (Connor, 2015). Reed has undergone afall and injured his left ankle. Further, the patient is sufferingfrom emotional distress. He acknowledges that he has been fightingall his life and would wish to have peace because of the problemsthat he has been facing. Hospice offers emotional and spiritualsupport that has been tailored to the needs of the patient. Reedneeds the care since his mother is not delivering the services as isexpected. Notably, the patient has been assessed and determined to besuffering and not well taken care of. His hygienic condition isdeteriorating, and the situation is made worse by him beingwheelchair bound. Hospice offers care to the patient to enable him toget the support that he needs.

Florida Department of Children and Family helps in the provision ofcare to patients of Reed’s caliber. Considering the nature of thecondition the patient is suffering, it is essential that he beassigned quality and professional care. Referral to Florida’sDepartment of Children and Family would be instrumental in enhancingthe condition of the patient. His mother is evidently tied up at workand not in a position to efficiently take care of him. FloridaDepartment of Children and Family would facilitate healing for thepatient because of the nature of services that the institutionoffers. He has a chance of getting quality care compared to when hehas to stay at home.

Culturaland Spiritual Consideration

Cultural and spiritual aspects are of crucial significance when itcomes to caring for the patient. One cultural aspect to be consideredis the patient’s background. For example, some cultures endow theresponsibility of decision making to the entire family and notindividual. Spiritual consideration could be religious background andability of patient to have faith in medicine used to treat him.

Assessment of BMI, Dietary Intake and Recommendation

Client’s Height, Weight, and a 24-hour Diet Recall

Weight is 147lbs

Height is 5`2&quot

BMI is given by

Weight /Height (m2)

BMI results for the patient is 26.89 kg/m2

Patient is severely thin indicating malnutrition. Normal BMI isclassified to being 18.5kg/m2 – 25 kg/m2.

The condition is an illustration of the overweight.

24-Hour Recall contains the following items

Cup-One 8-oz.

Bowls-2 different shapes each holding 2 cups

Small sauce dish- about ½ cup

Plastic ruler-6” is less cumbersome

Measuring teaspoons

1 tablespoon


½ teaspoon

¼ teaspoon

Plastic container having 2 to 3 cups of rice having a tight lid.

Plastic container having 2 to 3 cups dried beans.

Dietary Assessment and Recommendation

The patient is overweight as shown by the low BMI. It is essentialthat the patient be subjected to a diet that improves his nutritionstatus. He should start ingesting foods rich in proteins, vitamins,carbohydrates, lipids and mineral salts. It would be possible for thepatient to recover from the malnutrition. Nutritional guidance shouldbe provided to enable patient to recover from the condition.


Ball, J. W., Dains,J. E., Flynn, J. A., Solomon, B. S., &amp Stewart, R. W. (2014).Seidel`s guide to

physical examination. Elsevier Health Sciences.

Bogunovic, L., Gelberman, R. H., Goldfarb, C. A., Boyer, M. I., &ampCalfee, R. P. (2013). The impact of antiplatelet medication on handand wrist surgery. The Journal of hand surgery, 38(6),1063-1070.

Connor, S. R. (2015). Hospice and Home Care. Psycho-Oncology,6, 249.

Estes, M. E. (2013). Health assessment and physical examination.Cengage Learning.

McMahan, R. D., Knight, S. J., Fried, T. R., &amp Sudore, R. L.(2013). Advance care planning beyond advance directives: perspectivesfrom patients and surrogates. Journal of pain and symptommanagement, 46(3), 355-365.