Question

1. You are performing an assessment on a resident who is complaining of pain. Give examples of open-ended questions you would ask to get more information about their pain.
2. You walk into a resident’s room to answer their call light and you notice the resident is having difficulty breathing. Discuss what would be included in a focused assessment at this time?
3. objectives and subjective data for
System
Objective Data
Subjective Data
Gastrointestinal System
Neurological System
Genitourinary System
Musculoskeletal System
Cardiovascular System
Respiratory System

Answer 1

1. Pain is the one best indicator of subjective data and it should be assessed by asking specific open-ended questions.

• Show the place the pain hurting you? - To know the location of the pain.
• Does it transfer to anywhere else? - To know the radiation.
• Can you able to describe the characteristics of pain? - To analyze the quality of pain.
• What score did you give on the pain scale? - To detect the severity of pain
• What makes you more hurt and what helps you to feel better? - To know the aggravating and relieving factors of pain.
• when it worsens more and how long it hurts? - To know any specific timing in getting of pain.
• Does it interfere with any of your daily activities? - To know the impact of pain.

2. Focused assessment of breathing difficulty:

• Inspect for airway, breathing, and circulation.
• assess for use of accessory muscles for breathing.
• Check for breathing pattern, rate, and depth.
• Check oxygen saturation with the help of pulse oximeter.
• Check for any bluish discoloration of lips, hands, feet.
• Palpate the lungs for any swelling or edema.
• Auscultate the lung and posterior chest for the presence of any wheezing, rales, rhonchi, creaking, etc.
• Document the patient report.