Document: Focused History, Physical Exam, Nursing Diagnoses

Document a focused history, physical exam, nursing diagnoses, and nursing process of a case study from NUR-641E: Advanced Pathophysiology and Pharmacology for Nurse Educators and compare the differences with a complete assessment

Assessing a patient thoroughly is fundamental for effective nursing care. In the provided case study of a 22-year-old woman presenting with persistent flu symptoms, vomiting, dehydration, and abnormal blood gas values, a focused history and physical examination are essential to identify the immediate health issues, their underlying causes, and appropriate interventions. This approach contrasts with a complete assessment, which encompasses a comprehensive review of systems and detailed physical examination, providing a broader picture of the patient's overall health status.

Focused History and Physical Exam

The focused history in this case centers on the patient’s recent onset of symptoms, duration, and severity. The patient reports being “sick with the flu” for the past eight days, which indicates a potential viral illness. The prominent symptoms—vomiting multiple times daily, difficulty maintaining fluids, and use of excessive antacids—point toward gastrointestinal disturbances, possibly leading to electrolyte imbalance and dehydration. The history of fainting at home suggests significant dehydration and hypovolemia, necessitating urgent intervention.

The physical exam, although not detailed in the case, would prioritize assessing vital signs (e.g., heart rate, blood pressure, respiratory rate, temperature), hydration status (mucous membranes, skin turgor), and neurological status (mental alertness, level of consciousness). Given the dehydration, signs may include tachycardia, hypotension, dry mucous membranes, and poor skin turgor. The patient's fainting episode further underscores the need to evaluate for orthostatic hypotension and electrolyte imbalances.

Nursing Diagnoses

Based on the focused assessment, several nursing diagnoses can be identified:

• Dehydration related to excessive vomiting and inadequate fluid intake as evidenced by dry mucous membranes, low skin turgor, hypotension, and fainting.
• Anxiety related to acute illness and dehydration.

Nursing Process and Interventions

The nursing process involves assessment, diagnosis, planning, implementation, and evaluation. For this patient, immediate priorities include restoring hydration, correcting electrolyte imbalances, and monitoring for complications.

Interventions encompass:

• Administering IV fluids to rehydrate and restore electrolyte balance, specifically isotonic solutions like normal saline.
• Monitoring vital signs and neurological status to observe for signs of hypovolemia and dehydration
• Assessing laboratory results, especially electrolyte levels, blood gases, and renal function
• Providing antiemetic medications to control nausea and prevent further vomiting
• Educating the patient on avoiding excessive antacid use and managing nausea

Evaluation will focus on the improvement of hydration status, normalization of vital signs and blood gas values, and resolution of symptoms.

Comparison with a Complete Assessment

A complete assessment extends beyond the focused approach by systematically evaluating all body systems and health conditions, regardless of presenting symptoms. It includes detailed history-taking and physical examinations covering the cardiovascular, respiratory, gastrointestinal, neurological, musculoskeletal, sensory, integumentary, and psychological systems.

While a focused assessment is efficient for acute or specific complaints—like dehydration or nausea—comprehensive assessment provides baseline data, detects unrecognized health issues, and guides long-term care planning. For instance, a complete assessment might reveal underlying conditions such as diabetes, cardiac abnormalities, or chronic respiratory issues that influence management strategies.

In this case, a full assessment might uncover additional concerns such as murmurs, abnormal lung sounds, or other systemic dysfunctions, offering a broader understanding of the patient's health. However, in urgent situations like dehydration with abnormal blood gases, a focused assessment allows rapid diagnosis and intervention.

Conclusion

Effective nursing care for the patient involves a targeted, systematic approach combining focused history and physical assessment with diagnostic data to prioritize interventions. While a focused assessment efficiently addresses immediate needs, a complete assessment is valuable for comprehensive health evaluation and long-term health planning. Balancing these approaches allows nurses to deliver safe, effective, and individualized patient care.

References

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