Return of assignment:
This written assignment is designed to facilitate exploration of physical assessment using a clinical patient scenario. This assignment will incorporate focused assessment, normal and abnormal parameters and health history. Detailed information on available topics, content guide and expectations of writing and structure can be found on NRSG125 LEO under ‘My Assessments'.
Step 1: Select a case study from the two options below
Alice Palmer 54 yrs.
Ischaemic stroke
Mrs. Alice Palmer is a 54 year old woman who has been admitted to your unit. She had an ischaemic stroke 18 hours ago and has been transferred to the acute stroke unit to receive ongoing assessment and rehabilitation.
The previous nurse hands over to you: HR 89, BP 155/90, left hemiparesis and bilateral visual fields deficit. Glasgow Coma Scale score 15. Mrs. Palmer was also noted to have some difficulty with remembering recent information but can recall with some prompting.
You introduce yourself to Mrs. Palmer and her husband. Mrs. Palmer says that she has had hypertension ‘for years' but that she didn't really like to take medication.
You will need to complete the admission assessment(s) for Mrs. Palmer
Len Thompson 49 yrs.
Acute abdomen
Mr. Len Thompson is a 49 year old man who has had Crohn's disease for 12 years. He presents following two days of abdominal pain with frequent bouts of watery diarrhoea.
The previous nurse hands over to you: HR 120, BP 100/45, Temperature 36.9, severe abdominal pain with the last episode of diarrhoea being around 2 hours ago. The nurse also states that he is pale with dry mucous membranes, and that he is requesting a drink of water. Len's 12 year daughter is with him.
You are to complete the admission assessment for Mr. Thompson.
Step 2: Utilising elements of Levett-Jones (2013) Clinical Reasoning Cycle below, write a 1500 word essay, incorporating the following the information.
I. Consider the person's situation-
Identify and discuss the key elements of the demographic data recorded in your chosen scenario
II. Collect cues and information-
Review current and handover information.
Describe what additional information you may need
III. Process information-
Interpret what you currently know about presenting problem - what are the expected assessment parameters for this person's situation?
IV. Identify problems/issues-
Describe what focused health assessment/s you think you would need to use and why
Describe how your chosen person's findings differ from normal expectations
V. Detail the assessment-
Detail how you are going to undertake the health assessment - ensuring you describe the technique and person considerations.