Physical Assessment
Instructions
Purpose
As you are learning this semester, the role of the nurse is to integrate and apply knowledge from your general education background, health-related sciences, and evidence-based nursing science in the application of the nursing process to the nursing care of patients in the acute care setting. The nurse uses knowledge from pharmacology, anatomy and physiology, pathophysiology, microbiology, nutrition, psychology, and other sciences to build a plan of care according to the health assessment findings generated by the nurse. Nursing is practiced within an interdisciplinary health care system, and it is important for the nurse to understand the perspectives of other disciplines in their contribution to the patient plan of care. For this assignment, you will use the case study provided or choose a client from your clinical rotation. You will complete an in-depth analysis of the nature of their health alterations, the pathophysiological and psychosocial aspects of their health needs and how the interdisciplinary team contributes to the treatment plan while the patient is in the hospital and has plans for discharge are put into action.
Directions
- Read the information about the case study with the chart materials provided or gather the necessary information from one of your patients.
- Review the patient assessment information. What other assessments might you do in addition to those provided? What findings would you anticipate with this patient? Complete an in-depth analysis reflecting your ability to prepare a case study based on principles derived from pharmacology, pathophysiology, psychology, nutrition, and evidence-based nursing practice guidelines. Remember to include an introduction to the patient, pathophysiology, history, nursing assessment (given and any additional), and related treatments.
- Include selected references for your case study paper/care plan and use APA format.
- Specific grading rubric is attached.
Criteria
The case study is specific, analytical, conceptually sound and based on scientific principles and application of knowledge, reflects evidence-based nursing care approaches and science, and is holistic in its approach to understanding the patient and his/her nursing care needs.
Headings 1 -Introduction to patient
clearly explains who the patient is (age, gender, etc.), what the problem is, and what you are focusing on regarding care of this patient
Heading 2 Pathophysiology
Clearly and concisely discusses the disease, manifestations, and causes
Heading 3 History
Clearly and concisely discusses patient’s health history & past treatments including prior surgeries and prescribed medications
Heading 4 Nursing Physical assessment
Clearly and concisely lists all patient’s assessment data in sentences with specific numbers/levels
Heading 5 Related treatment criteria
Clearly and concisely explains what treatments the patient is receiving because of his/her disease
REFERENCES
Patient name on my clinical rotation
P. Smith, 57 years old Female
Admitted : Patients has tracheostomy ,
Came in for for physical and cognitive rehab
Family history unknown family history because patient adopted child.
Vitals – Respiration 24 and pulse rate 70
Medical Diagnosis- Acute respiratory failure with hypoxia
My Nursing Diagnose-Impaired verbal communication related to tracheostomy as evidence by difficulty speaking
Health history
COPD — Patient dependent of respirator or ventilator,
- Pulmonary embolism without acute pulmonale
- Acute embolism and trombosis
- Encounter for attention of tracheostomy
- Atrial fibrillation
- Cognitive communication deficit
- Major depressive disorder
- Atherosclerosis of aorta
- Hypokalemia and hyperthyroidism
- Patients left leg swollen
Surgery -Tracheostomy
Medication
Biofreeze gel
Vent order 500 vent rate 14 breath per minute
Ipratropium-albuterol-
Norco
Hyddrocodone
Lorazepam
Check ventilator/ trachc every 6 hours, Oxygen 90% and above
Derma fungal for infection
Gabapentin capsule-nerve pain medication and convulsant
Patient Diet- Generalized diet, regular texture and thin liquid consistency.
- In a calorie count
Patients states 0 pain level out of 10
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