What assessment findings are abnormal?
What is the reason (pathophysiology) for these findings?(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT
Assessment Data:Clinical Significance:Put it All Together and Think Like a Nurse!
1.Interpreting relevant clinical data, what is the most likely primary problem?
What body system(s) will you assess most thoroughly based on the primary/priority concern?What’s the problem?
What’s causing the problem?(explain pathophysiology in OWN words)
PRIORITY
Body System to Assess:
GENERAL APPEARANCE: Obese-female is sitting upright in bed.Alert, oriented, pleasant, in moderate distress, dress appropriate for the season, hygiene and grooming normal for age and gender, anxious, body tense, +grimacing, appears to be uncomfortable.
RESP:Breath sounds clear on inspiration and expiration in all lobes anterior, posterior, and laterally,with equal aeration bilaterally ant/post, non-labored respiratory effort with + tachycardia.
Posture erect, sitting in bed, in moderate distress, on room air, AP diameter 1:2, symmetry of the thoracic cavity noted with inspiration and expiration
CARDIAC:Pink,warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post–tibial landmarks, brisk cap refill, carotid pulse 3+ and regular bilaterally. Heart tones audible and regular, S1 and S2,noted over the 5cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30–45 degrees.
NEURO:Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally.
GI:Abdomen flat, soft, bowel sounds audible per auscultation in all four quadrants, non tender to gentle palpation in all four quadrants
GU:Voiding without difficulty, dark amber/rusty color with recent void to collect urine specimen
INTEGUMENT:Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds.Hair short, brown, soft. Hair distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present
2.Which specific nursing assessments for this body system are most important? Validate successful completion of each nursing assessment on a manikin (if available) identified with peer or faculty initials.
PRIORITY
Nursing Assessments:Rationale:Validate Student Performance.
3.What is the current nursing priorityand plan of care? Nursing
PRIORITY:PRIORITY Nursing Interventions:Rationale:Expected Outcome:
4.State the rationale and expected outcomes for the medical plan of care.
