Physical Assessment Case Question & Answer Guide (With Explanation)

This question focuses on applying theory to practical scenarios.

What This Question Is About

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How to Approach This Question

Focus on explaining concepts clearly and supporting them with examples.

Key Explanation

This topic involves physical assessment case. A strong answer should include explanation, application, and examples.

Original Question

Physical Assessment. The case of my client an 92-year-old Caucasian resident of an assisted living facility, exhibiting productive cough with complaints of shortness of breath and was diagnosed with bacterial pneumonia and subsequently c.diff after a second round of antibiotics. She also complained of chronic bilateral knee pain. She also had a history of dementia, asthma, osteoarthritis, COPD, and is considered legally blind. Due to the above scenario my client may exhibit the following: Head, Ears, Eyes, Nose & Throat: My patient is wearing dentures. She is also noted to be legally blind, therefore the visual acuity test to determine the smallest letters she can read was not tested. The area that was tested are as follows: Neck and Shoulders: My client perform normal range of motion in the neck and shoulders. There are no lymph nodes palpated during examination. Lungs And Respiratory System: Productive cough with complaints of shortness of breath. She is a smoker of 60 years and often asks for a cigarette. My client has bacterial pneumonia, GI and GU Assessment: My patient was noted to be continent of bowel and bladder. Pulses and Extremities: My patient ambulates independently without the use of an assistive device. She has chronic bilateral knee pain. Neurology: My patient has a history of dementia, however, during assessment and interview, patient was coherent and able to respond appropriately. Nursing Diagnosis Ineffective Airway Clearance related to sputum production as evidenced by productive cough with complaints of shortness of breath. Impaired Gas Exchange related to collection of mucus in airways as evidenced by complaints of shortness of breath. Activity Intolerance related to imbalanced between oxygen supply and demand due to inefficient work of breathing. Chronic pain related to joint degeneration. Risk for Injury related to impaired sensory function. In this third and final submission of your Course Project, you will be completing the comprehensive care plan. Include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion. This written assignment should include the following: Your Nursing diagnoses from Part 2 (use the table below) One short term goal and one long term goal per NDx Four Nursing interventions per NDx .. Prioritization per Maslow with an explanation and an expected evaluation. Make sure to include a teaching plan in your care plan. Upload the table below into your paper. Reflect on the following in your paper: Which of your nursing diagnoses are priority using Maslow’s Hierarchy of Needs? If you were to implement this plan of care, would you expect any of your short-term expected outcomes met during your shift? Explain. How might you revise your care plan next time to achieve at least one outcome during your shift? Nursing Diagnoses Use your Assessment data to ID clinical problems Expected Outcomes (S.M.A.R.T.) Specific, measurable, attainable, realistic, & time-oriented (ID a future time or date for reassessment/evaluation) Nursing Interventions What can you, the nurse, do to reach the goal and improve the problem?

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