Nursing Asssessment-Focus scenario Case Study Example | Topics and Well Written Essays - 750 words

Nursing Asssessment-Focus scenario - causal agency Study ExampleHis diet includes organic food from animals, fruits and vegetables present in his farm. He is also a frequent alcoholic beverage drinker, with two to three bottles of beer every evening. No tarradiddle of cig bette take in had been mentioned. Mr. S has a family history of substance attack, breast cancer and hypertension. Occasionally he complains of shortness of snorkel which is relieved by rest. He thinks that he is in good health considering the time he spends outdoors.A thorough health history must be established in order to provide a comprehensive nursing assessment. This may be done through interview or reviewing past medical checkup records. Components of a nursing health history include biographic data, such as age, gender, occupation and commonplace source of medical c atomic number 18, chief complaint or the reason for visit, history of present illness, past history and family history. Lifestyle, social d ata like economic status, ethnic affiliation and neighborhood conditions, and psychological data are also considered. When assessing the history of the present condition, the onset of the symptoms, characteristic of the complaint, activity in which the patient was involved when the riddle occurred and any aggravating or alleviating factors are noted.Proper physical examination using effective tools are vital to come up with a diagnosis and to establish nursing care. A common rule to identify problems is the review of systems. In this process, each body system is assessed for specific signs and symptoms that may be attributed to a deviation in the normal functioning of that organ system. In the case of Mr. S, vital signs would consent to be taken to acquire baseline data. Blood pressure is obtained using a sphygmomanometer and a stethoscope, heart rate and respiratory rate through a stethoscope, and temperature reading through the use of a thermometer. service line height and weig ht should also be measured using a tape measure and a weighing scale. Mr. S complained of shortness of wind relieved by rest and has a history of cardiovascular disease therefore, data regarding cardiovascular and respiratory system must be reviewed. Aside from the heart rate, circle and heart sounds are also assessed, again through auscultation using a stethoscope. These are some of the parameters utilize in evaluating cardiovascular function. Assess for presence of edema, which is evident in Mr. S. Perfusion can also be obtained by noting if he is warm, dry, or diaphoretic. Respiratory system review consists of observing the breathing pattern and breath sounds, presence of secretions and cough. Shortness of breath may suggest, but is not limited to, a pulmonary problem. Since Mr. S is having edema, suffering will also have to be assessed. If pain is present, he could use a pain rating scale to be able to determine its severity. Genitourinary system must also be evaluated. His intake and output must be monitored. Ask when he last voided. Assess also for signs and symptoms of anuria, hematuria, dysuria or incontinence. This could reflect whether his edema and weight gain are brought about by a genitourinary problem. kowtow assessment is done by noting presence of warts, moles, unusual discoloration, jaundice, scars and skin color. Jaundice may reflect hepatic dysfunction, in which edema may also be attributed. His lifestyle, involving drinking two to three beers every night, makes him at high risk for renal and hepatic diseases.