Scenario
Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies.
On admission, he states that he hasn’t been feeling well for 3-4 days, complained of dyspnea, generalized body pain, fatigue, and a productive cough of yellow colored sputum. He has not slept in 2 nights, is agitated, anxious about his health and reported feeling weak. Mr. Lawson has little appetite and is mostly eating soup even though the doctor ordered a regular diet. He is alert and oriented x 4, continent of bowel and bladder and on bed rest due to weakness and unsteady gait.
Physical assessment reveals B/P 168/90; pulse 104; respirations 26; temperature 98.9 F; oxygen saturation 93% on o2 2L via NC with diminished breath sounds bilateral and expiratory wheezing on auscultation. Bowel sounds are present on all four quadrants, heart sounds are regular and his skin is intact. I.V. antibiotics are ordered and started.
QUESTION: What I really need help with is explaining this scenario in a narrative format using the assessment phase of the nursing process.
In a narrative explanation, explain the assessment phase of the nursing process and include objective and subjective questions for the holistic assessment (5 dimensions of man) of the patient including the vital signs.
Narration refers to telling something on a firm of story.In this case the patient is a known case of COPD and Hypertension. Usually an objective data or assessment is the first thing carried out by the healthcare professionals.The patient can be observed for dyspnea,anxiety and anxious, unsteady hair, generalised weakness,coughing.Vital signs assessment indicates that his blood pressure is elevated (168/90 mmHg)tachycardiac(104) tachypenic(26), hypoxic(Spo 93%)
Auscultation reveals wheezing on expiration. This indicates the patient is experiencing exacerbations of COPD and needs antibiotics to cope up.
The subjective questions for assessment can be made in the following way
Scenario Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history...
Scenario Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies....
Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed, and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies. On...
Explain how the professional nurse utilizes the nursing process in the nurse-client relationship: Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity...
Explain how the professional nurse utilizes the nursing process in the nurse-client relationship: Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity...
Mr. S.L is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies. On admission,...
SCENARIO: Mr. M, a 42-year-old thin male with a history of schizophrenia, is brought to the emergency room from an assisted living facility because of worsening delusions along with hypertension. Staff at the assisted living home reported that he has been increasingly agitated and physically aggressive at times. His delusions consist of creatures from outer space who are trying to kill him. He appears to be experiencing visual hallucinations and states that he sees creatures in the corner of the...
Brief Patient History Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously (IV) to achieve hemodynamic stability. Clinical Assessment...
Brief Patient History Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously (IV) to achieve hemodynamic stability. Clinical Assessment...
Brief Patient History Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously (IV) to achieve hemodynamic stability. Clinical Assessment...
History: Mr. Dan Griffith is a 65 year old male who presented to the emergency department with shortness of breath and chest tightness of recent onset. He has a 7 year history of COPD and is on oxygen at home. Physical assessment reveals a respiratory rate of 32 and slightly labored, temperature of 98.9, and SpO2 of 86% while on oxygen via nasal cannula at 2 L/min. Question: Mr. Griffith is admitted to the pulmonary unit with acute exacerbation of...