Question

The history describes your patient as a 38-year-old married woman, the mother of two children in the sixth and eighth grades. She works full-time as a paralegal professional. Her past medical history is listed as a tonsillectomy at age 8 years and a urinary tract infection at age 14 years (none since then). She has sought healthcare at this clinic for the last 2 years and had a comprehensive assessment when she entered the system. Her husband says that she has been fatigued for the last 2 weeks and that she gets short of breath on exertion. The patient’s reason for seeking care is “stabbing chest pain on my right side when I take a deep breath or cough.” Her height is 67 inches (170.2 cm), weight is 160 lb (72.7 kg), and she is alert and oriented. Her vital signs are temperature 102.2ºF (39ºC), pulse 120 beats per minute and regular, respirations 32 per minute and regular, blood pressure 152/80 mm Hg. She is coughing up moderate amounts of thick, yellow sputum. A pleural friction rub is present.

   1.   Construct a list of which data presented in the situation are primary data and which are secondary data. Determine which data are subjective and which are objective.

   2.   Develop the order in which you would collect your assessment information about the patient.

3. Using a functional health, head-to-toe, or body systems framework, cluster the data into meaningful groups.

   4.   Select which data are of priority and which data are irrelevant at this time.

   5.      Determine if you are able to make a nursing diagnosis at this time. If yes, identify the diagnosis. If not, explain why.

Answer 1

1, Primary data: Data obtained by the health care professional from the patient as the patient's previous medical history of tonsillectomy at age 8 years, UTI at age 14 years, health care assessment last 2 years back.
secondary data: Data gathered by someone. her husband says she is fatigued for the last 2weeks and gets sort of breath on exertion.
subjective data: The information from the client that symptoms include stabbing chest pain on the right side when on deep breath or cough.
Objective data: conservation, physics, exam, lab test by the health care professional. it includes patient vital signs, pleural friction.
2, Assessment of physical, mental, and neurological: the patient is alert and oriented.
Vital signs:temperature-102'2degree f, pulse-120beats per minute and regular, respiration -32/minute and regular,blood pressure 152/80mmHg
Airway assessment: breathing difficulty, cough, respiration rate: 32 b/minute
Lung assessment: pleural friction rub is present
CNS assessment: fatigue
3, patient history: 38-year-old female with two children, works full-time as a paralegal professional, has a past history of tonsillectomy, UTI, and complete health care assessment done 2 years back.
general appearance: alert and oriented
Vital signs: temperature 102.2degree F, respiration - 32 b/m, pulse- 120b/m, BP- 152/80mmHg
Weight : 160Lb, height -67inches
physical assessment includes a physical examination by
Observation: alert and oriented
auscultation - pleural friction rub present
Airway- cough
Breathing- pleural friction, respiration-32b/m.
circulation -T-102.2degree F, pulse -120b/m
Observation: chest pain on deep breathing, think yellow sputum present with coughing.
focused assessment: fatigue, stabbing chest pain on the right side when on coughing.
4, priority for primary data includes stabbing chest pain on the right side when taking deep breath or cough and irrelevant data will be patient last physical assessment 2 years back at this time.