Techniques in Performing a Clinical Assessment - Essay Example

The visual assessment will encompass looking for anomalous shape, color, size, and texture among other aspects. Generally, nurses utilize physical assessment expertise and skills to identify the patient’s problems and develop a basis of data and information, which are utilized for subsequent nursing processes (Cox & Turner, 2010).

            I will explain to the student the assessment techniques that are involved in the physical assessment including palpation, percussion, and auscultation. Palpation incorporates the utilization of hands to feel the body organs in enabling the assessment of abnormal shape, size, level, and location of the pain. On the other hand, Percussion incorporates the generation of sound by scrapping or tapping the body part to determine the parameters including the organ density and size (Cox & Turner, 2010). Consequently, auscultation entails listening to the sound produced by various organs like the throat and lungs. These are the assessment techniques utilized in Evelyn’s scenario:

Assessment Techniques

            The order of the assessment techniques includes Inspection; Palpation; Percussion and lastly Auscultation:

1. Inspection

            The critical observation is conducted first whereby the nurse takes appropriate time in observing the patient with all senses including eyes, nose, and ears. In this process, the nurse must utilize good lighting in order to ascertain his observation of color, shape, position, and symmetry. Consequently, observation of odors of the skin and mouth is essential (Sawyer, 2012).   

1. Palpation

            In this process, deep (5-8 cm) and light (1 cm) touch by the back of the nurse’s hand (or fingers) is utilized to assess the patient’s skin temperature. Consequently, use fingers to inspect the moisture, tender areas, and texture.   

1. Percussion

            This is an essential part of the physical assessment where the nurse strikes the body surface to generate sound.  The following sounds; resonant, dull, flat, and tympanic are utilized to determine the shape and size of underlining structures in the relevant body organs (Sawyer, 2012).

1. Auscultation

            This assessment mostly utilizes a stethoscope for indirect auscultation but in obvious cases, nurses listen to sounds generated by specific body organs. Direct auscultation entails listening to the service user from a given distance or resting the ear on the skin’s surface (Sawyer, 2012).

Nursing care Plan for Evelyn after assessment

• 38 years old
• A single mom with three children, and lives with two of them
• Works full time and spends most of her free time with her children and sickly grandson Ryan who seems undernourished
• After caring for her grandson who had a “terrible cold”, she developed a cold too
• Complains of a sore throat, head pain, and coughing
• Her head pain is centered over her head
• Upper teeth and jaws hurt
• The pain aggravates in the morning and exhausting activities worsens the head pain

Recording

            The SOAP method is utilized in the case scenario to assist in the data recording to effectively complete a reliable entry. The format utilized in recording the data entails:

            S- Subjective data: record the patient’s condition, which will include the characteristics of pain and aggravating factors.

            O- Objective findings: the physical assessment evidence generated from the examination is then recorded regarding the condition of the patient.

• Assessment: a record of the nurse’s assessment of subjective and objective findings, and complaints are included.

P- Plan- entails the nurse’s plan for current and future treatment.

Influenza (flu) Diagnosis

            A nursing plan is developed to tackle a nursing diagnosis of influenza based on symptoms of influenza including cough, fever, cold, sore throat, and head pain. Onset severe signs and symptoms also include diminished breathing sounds, a lucid nasal discharge, a reddened nose, and enlarged lymph nodes. The nursing diagnoses are:

• Risk for deficient fluid in the body as a result of dehydration and,
• Ineffective airway clearance due to secret build-up and inflammation

            The nursing interventions may include helping the patient to cough up the suctioning or secretions. It is also recommended for the patient to rest until the influenza is resolved fully. The patient should drink a lot of water to deal with dehydration. Antiviral treatment, which is essential in the treatment or prevention of flu, can help in tackling the conditions. However, if the medicine fails to eliminate the influenza symptoms; though, it is essential in reducing the duration and severity of the symptoms (Ladwig & Ackley, 2013).

Patient Education

            Patients with influenza must have a high level of personal hygiene, especially respiratory hygiene. Respiratory hygiene will entail putting on a mask when coughing as well as coughing into tissues and sleeves. Consequently, Evelyn should wash her hands regularly especially after coughing (Carpenito, 2009).  To regulate and control seasonal influenza, immunization has proven to be an effective way. Therefore, annual immunization and vaccination are vital preventive measures that Evelyn can utilize. The client education strategy will encompass a one-on-one communication process whereby the nurse will explain the prevention measures Evelyn ought to undertake (Doenges, Moorhouse & Murr, 2013). The effectiveness of the educational intervention will be known when Evelyn will not report back to the clinic with the same symptoms of influenza