Question

Ms. Kline, a 55-year-old white woman, arrived at an urgent care center complaining of generalized malaise, an overwhelming feeling of exhaustion that was not relieved with rest, and difficulty walking more than 10 ft. She has thinning scalp hair, scaly skin, and puffiness around her eyes. She appears to be anxious. She is married and responsible for raising three grandchildren (2, 4, and 8 years old). She is employed full time as a college professor, and is worried that she may have a serious condition that will compromise her ability to work and care for her grandchildren. She enjoys gardening and reading books. Her vital signs are T 36° C (36.8° F), BP 102/68, P 68 and regular, and R 12 and unlabored.

1. The nurses use the nursing process to care for Ms. Klein. Identify methods used during the assessment phase of the nursing process:

2. Describe the 4 assessment techniques used during physical assessment:

a. The nurse listens to Ms. Klein’s breath sound. Which of the physical assessment techniques did the nurse use?

b. According to the case study, Ms. Klein has thinning scalp hair, scaly skin and puffiness around her eyes. Which assessment technique did the nurse use to obtain such information?

3. The three types of physical assessments are: complete physical assessment, (2) focused assessment, (3) emergency assessment.

a. Differentiate among the three types assessment.

b. Identify the type assessment that the nurse performed on Ms. Klein.

4. During assessment, various types of data are collected include: Primary data, secondary data, subjective data, and objective data

a. Define each of the previous data collection methods and give examples of each.

b. Classify each piece of Ms. Kline's data in the case study as subjective or objective.

5. After the data are collected from Ms. Klein, the nurse organized the data according to established frameworks.

a. Define the three most commonly used methods of organizing patient data.

b. Organize the assessment findings from Ms. Klein into functional health patterns.

Answer 1

1, Assessment process include palpitation, percussion, inspection, auscultation during physical assessment.
2, Inspection: visual examination of the patient.
Palpitation: Placing the finger on the body to find swelling, masses, and pain
Percussion: Tapping the patient body surface to hear the sound of air and water
Auscultation: Listening to the sounds with a stethoscope
a, Breath sounds can be heard through auscultation by listening to the sounds with the use of a stethoscope.
c, Inspection is a visual examination of the patient. patient scalp and puffiness around her eye can be assessed by inspection.
3, a, complete physical assessment includes inspection, palpation, percussion, and auscultation including neurological assessment.
Focused assessment includes a detailed nursing assessment about a specific body system regarding their present illness.
The emergency assessment focuses on concern with the patient emergency condition to assess the airway, breathing, circulation(ABCs) of the patient. it includes focus assessment and complete physical assessment as per the patient situation.