Tonya returns to Mr. Lawson's room to discuss his discharge instructions, but she notes as she enters the room that the patient is grimacing. She asks him, “Tell me where the pain is.” Mr. Lawson is asked to rate the pain on a scale of 0 to 10 and rates it a 6. Tonya looks at the patient's surgical wound and notes that the area of separation is still inflamed. Match the assessment technique on the left with the type of measurement on the right. 1. Patient rates pain 6 on a 0 to 10 scale. ___ A. Determining location of a symptom 2. Tell me where the pain is. ___ B. Observation 3. Patient is seen grimacing. ___ C. Inspection 4. Nurse looks at condition of wound. ___ D. Determining severity of a symptom
Matching the correct assessment technique of left with the type of measurement on the right:
1. Patient rates pain 6 on a 0 to 10 scale - D. Determining the severity of the symptom
2. Tell me where the pain is - A. Determining the location of the pain
3. Patient is seen grimacing - B. Observation.
4. Nurse looks at the condition of the wound - C. Inspection
Rationale for the assessment:
1. The pain scale is used to assess the intensity and severity of pain using a pain scale. The scale consisted of 0 - 10 where 0 indicates no pain and 10 indicates the worst pain.
2. Open-ended question helps to identify the exact location of the pain. So that the appropriate measures can be taken to minimize the pain.
3. Observation is an important part of the nursing assessment. Observation helps to identify the changes in the patient and to determine the clinical condition of the patient.
4. Inspection is the first part of the Physical examination. It is a careful observation of the patient clinical condition which is an initial step in the nursing process.
Tonya returns to Mr. Lawson's room to discuss his discharge instructions, but she notes as she...
Tonya is planning to return to Mr. Lawson's room and spend more time discussing his concerns about going home and what to expect. She knows that Mrs. Lawson usually comes to visit around 11 AM, just before lunchtime. Tonya believes that Mrs. Lawson will be an important source of support in providing Mr. Lawson's ongoing home care. The surgeon has ordered directions for wound care and standard activity restrictions. 1. Tonya goes to Mr. Lawson's room and asks the patient,...
UNIT-3-Clinical Practice Preparing for Clinical Practice Critical Thinking in Nursing Practice Medical treatment stabilized Mr. Lawson's condition. He had a pulmonary embolus, but he is now on anticoagulants, medications that will reduce likelihood of more clot formation. Knowing that Mr. Lawson is on anticoagulants and has had recent surgery and the processes of normal wound healing (see Chapter 48 (Links to an external site.) Links to an external site. ), Tonya believes that the patient is at risk for bleeding...
UNIT-3-Clinical Practice Preparing for Clinical Practice Critical Thinking in Nursing Practice Medical treatment stabilized Mr. Lawson's condition. He had a pulmonary embolus, but he is now on anticoagulants, medications that will reduce likelihood of more clot formation. Knowing that Mr. Lawson is on anticoagulants and has had recent surgery and the processes of normal wound healing (see Chapter 48 (Links to an external site.)Links to an external site.), Tonya believes that the patient is at risk for bleeding from his...
Medical treatment stabilized Mr. Lawson's condition. He had a pulmonary embolus, but he is now on anticoagulants, medications that will reduce likelihood of more clot formation. Knowing that Mr. Lawson is on anticoagulants and has had recent surgery and the processes of normal wound healing (see Chapter 48 (Links to an external site.)Links to an external site.), Tonya believes that the patient is at risk for bleeding from his surgical wound. She acts by increasing assessments of the wound and...
Critical Thinking in Nursing Practice Medical treatment stabilized Mr. Lawson's condition. He had a pulmonary embolus, but he is now on anticoagulants, medications that will reduce likelihood of more clot formation. Knowing that Mr. Lawson is on anticoagulants and has had recent surgery and the processes of normal wound healing (see Chapter 48 (Links to an external site.)Links to an external site.), Tonya believes that the patient is at risk for bleeding from his surgical wound. She acts by increasing...
Mr. Lewis is a 88-year old man brought to the emergency room by his daughter after finding him in his bedroom, lying on the floor beside his bed. Mr. Lewis is in obvious pain. He is wheeled into the ER by his daughter. He is moaning and rubbing his right leg. Pausing after every few words to catch his breath, he tells the nurse, “My leg is killing me. It keeps tightening and releasing. I cannot stand on it. It...
Mr. Lewis is a 88-year old man brought to the emergency room by his daughter after finding him in his bedroom, lying on the floor beside his bed. Mr. Lewis is in obvious pain. He is wheeled into the ER by his daughter. He is moaning and rubbing his right leg. Pausing after every few words to catch his breath, he tells the nurse, “My leg is killing me. It keeps tightening and releasing. I cannot stand on it. It...
unit-4 clinical practice Ethics and Values You are caring for a 17-year-old female patient with sickle cell disease who has been admitted for treatment of sickle cell crisis. Sickle cell disease is a genetic abnormality that affects hemoglobin in the red blood cells. In a sickle cell crisis weakened red blood cells clump together and impede blood flow, causing extreme pain. To prevent stroke and manage the pain of the crisis, your patient needs aggressive fluid and comfort management. At...
Ethics and Values You are caring for a 17-year-old female patient with sickle cell disease who has been admitted for treatment of sickle cell crisis. Sickle cell disease is a genetic abnormality that affects hemoglobin in the red blood cells. In a sickle cell crisis weakened red blood cells clump together and impede blood flow, causing extreme pain. To prevent stroke and manage the pain of the crisis, your patient needs aggressive fluid and comfort management. At the change-of-shift report,...
unit-4 clinical practice Ethics and Values You are caring for a 17-year-old female patient with sickle cell disease who has been admitted for treatment of sickle cell crisis. Sickle cell disease is a genetic abnormality that affects hemoglobin in the red blood cells. In a sickle cell crisis weakened red blood cells clump together and impede blood flow, causing extreme pain. To prevent stroke and manage the pain of the crisis, your patient needs aggressive fluid and comfort management. At...