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Nursing Assessment - Coursework Example

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Assignment II: Coursework; Physical Assessment and Application of Clinical Judgment Author Institution Physical Assessment and Application of Clinical Judgment Case Study 1: Obtaining a prioritized health history requires interpersonal and professional skills…
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Nursing Assessment
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Download file to see previous pages Firstly, the patient should be asked about the details of the shortness of breath by defining the symptoms as well as finding how long the patient has been in that condition. Some of the main variables to identify in the symptoms include onset time, location, severity, duration, radiation and quality. Secondly, there would be the establishment of the history of symptom obtained through talking to the patient about the frequency of short breath. This may uncover the pattern in the symptom presentation and may help determine any respiratory problem if the patient reports regular physical exertion. Thirdly, there will be discussion on pre-existing patient's condition in order to obtain a comprehensive medical history about the patient. Any information on hospitalizations of the patient enhances determination of factors that can result or contribute to breathing difficulties. At this point, the medications should be discussed since some drugs may result side effects, including the shortness of breath. The other questions will involve the eating habits. For coughing, the patient should be asked the frequency of coughing and the duration of coughing. The information on the blood or mucus and the color can necessitate getting of some information. The patient will then be asked how the obesity condition affects the life quality like disrupted routines (Beaman, 2011). Physical examination may involve first determining the BMI and examining the body clearly. Secondly, the lungs must be examined. This involved determination of the body weight, temperature and the body mass index (BMI) that entails measuring the height in order to enhance the determination of the effects of weight of the health condition. Also, this would involve listening to lungs and heart beat using stethoscope. Checking of the signs of blood backing up in the neck veins may facilitate determination of cor pulmonale disorder of the heart. Then there should be a full cardiac examination that involves listening to the six sections of the heart with the diaphragm and the bell of the stethoscope. This may reveal underlying cardiac condition like murmur which results from incompetent heart valve. Thereafter, the respiratory rate of the patient must be measured to enhance quantification of the shortness of breath. The normal respiratory rate for an adult ranges from 12-18 breaths per minute and the extent of deviation from the normal rate indicates the severity of the patient’s breathing condition (Utian, 2004). Pressing the abdomen enhances determination of abdominal palpation. The lips and fingers must be assessed for cyanosis while fingers must be checked for any clubbing. Physical examination might be a little painful, especially the abdominal palpation. Prioritized health history and physical assessment enhances diagnosis, and must be performed on a regular basis as they may reveal risk factors that suggest increased risk. The physical risks will enhance assessment of severity of conditions such as the inability of completing full sentences without having to take a breath (Beaman, 2011). A prioritized history and assessment of the heart enhances the exclusion of heart diseases associated or, which may result into a similar situation. Based on the assessments above, two interventions that I would prioritize include heart and lung interventions; heart failure and pulmonary hypertension for the ...Download file to see next pagesRead More
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