Demonstrate documentation of the lung and thorax assessment findings
Explain how to conduct a physical assessment of the lung and thorax
In this writing assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client. You can access the grading rubric for this assignment here: Writing RubricPreview the document.
A three-page (750-word) paper
Review the case scenario.
Kelsey Young is a seven-year-old African American girl who presents to the clinic today with her mother, Angie Young, as a follow-up to a visit to the emergency department after she had an episode of breathing difficulty the day before.
Onset: You ask Kelsey to describe what happened that brought her to the ER yesterday. She tells you she was at school and was coughing and couldn’t stop, and then her chest felt really tight and she felt like she couldn’t breathe right. She says that she got really scared, and the school nurse called an ambulance and her mom. You asked Kelsey if that ever happened before and she says no. You ask Mrs. Young if Kelsey has had any other respiratory or breathing problems. She tells you Kelsey always has a cough in the morning, but it seems to get better, and she never complains about it at school. She does get frequent colds, though. You ask Kelsey and Mrs. Young if she has noticed Kelsey has difficulty breathing or complains of chest pain. Kelsey tells you sometimes at recess she has trouble keeping up with the other kids because her chest hurts, and it is hard to breathe. Mrs. Young validates that she has noticed this as well.
Location: You ask Kelsey to show you where her breathing feels bad, and she points to her chest area.
Duration: You ask Mrs. Young to describe how long the coughing and shortness of breath has been occurring, and she tells you for about a year or so.
Characteristics: You ask Kelsey to describe what it feels like when she has trouble breathing or coughing. She tells you that her chest hurts and her breathing feels “funny,” not like normal. She tells you her coughing makes her chest feel funny too.
Aggravating factors: You ask Kelsey to tell you what makes her breathing feel worse. She tells you it gets worse when she runs around. She also tells you she coughs and sneezes a lot when she plays with her new kittens, Chico and Kiekie. She also tells you her chest sometimes hurts when “daddy smokes.”
Alleviating factors: You ask Kelsey what makes her breathing better and she tells you she’s not really sure, it just usually gets better.
Other background information: Kelsey is one of two children, and she has a younger brother, Marcus. Her father is an accountant and is a smoker. He has tried to quit but has been unsuccessful. Her mother is a stay-at-home mother and is very involved with her children. Kelsey loves to read, watch movies about animals, and play with her cats.
You perform the following assessment:
Lungs: Expiratory wheezes, otherwise clear
Thorax: Normal findings upon exam
Diagnosis and treatment: After ruling out other causes, Kelsey is diagnosed with asthma. She is placed on inhaled corticosteroids, an albuterol rescue inhaler, and Claritin for her allergies. Mrs. Young is advised to consider removing the kittens from the house and to have Mr. Young stop smoking in the house.
Provide answers for each item below.
You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills. In your paper, discuss the following items:
Write a detailed explanation describing what you would say to the student, explaining the assessment conducted and the findings. Discuss the thorax assessment you performed and any additional assessments you would perform. What are other factors related to the probable diagnosis you would be concerned about with this client?
Explain how you would document your findings in the medical record.
Develop your plan of care. Identify one to two nursing diagnoses and one to two nursing interventions related to those diagnoses. The interventions need to be evidence based. Cite the references used in your plan in correct format.
Identify what client education (including creating an asthma action plan for the client) should be done for Kelsey, given her background and presenting illness. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention.
Save and submit your assignment.
When you have completed your assignment, save a copy for yourself in an easily accessible place and submit a copy to your instructor using the dropbox.
Giddens, J. F. (2010). The neighborhood: faculty navigation guide. Upper Saddle River, NJ: Pearson Education, Inc.
Mayo Clinic Staff. (2010, September 21). Childhood asthma. Retrieved from http://www.mayoclinic.com/health/childhood-asthma/DS00849
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