Reference no: EM131642261
Health Assessment - Nursing 302 Spring 2017
At the conclusion of this lesson, students will be able to:
Identify relevant assessment data gathered during physical examination questions to ask for assessment of the head, face, neck, and skin when gathering history.
Differentiate abnormal and normal findings of the face, eye, skin, and neck.
State and Apply the four (4) techniques required for assessment of the head, face, neck, and skin.
Utilize critical reasoning in the collection and synthesis evaluation and communication of health assessment findings.
Case Study K.B.
K.B. is a 39-year-old AAF female who drove herself to the Urgent Care Center with complaints of sudden right sided facial weakness and drooping over the last twenty-four hours. She reports that the symptoms started after she left her job as an Administrative Assistance for a local RealEstate Firm. The client states that she also have right-sided ear and jaw pain with a lump in her neck. The client is concerned about eating although she denies difficulty swallowing. The client's vital signs are; Temp 101.2, Heart rate 99 Respiration18, and Blood Pressure 120/76. With tears in her eyes, the client states that she has a history of Herpes Simplex Virus ( HSP) that she contracted from her husband before they were divorced and frequent upper respiratory infections. Her current medical history includes an upper respiratory infection in which she reports having one week ago. K.B. was given a prescription for Zithromax 500 mg for five days in which she only completed three days of the antibiotic. K.B. also takes Valtrex 500 mg daily to prevent reoccurrence of the herpes virus outbreak. K.B is an only child who is in her second year of college majoring in Business Administration. Both of her parents are living. Her mother has a history of diabetes, and high blood pressure and her father have no significant medical history.
Based on the history and information presented, use the SOAP method to document your findings while completing your nursing assessment.
Explain two techniques that you would include in the assessment of your client. Why?
Using the above scenario identify normal and abnormal characteristics of the head, face, skin, and neck
List four therapeutic questions you may ask when communicating with your client
Please input pertinent data in all sections of the Health History (use the template in your laboratory workbook or create your own in a table format).
Biographic data
Reason For seeking Care
Present health illness
Past History
Medication reconciliation
Family History
Review of systems
Activities of daily Living (ADLs)