Question

Please have knowledge befoe answering this!

Judith Kline (J. K.), a 55-year-old woman, arrived at an urgent care center complaining of generalized malaise, an overwhelming feeling of exhaustion that was not relieved with rest, and difficulty walking more than 10 ft. She has thinning scalp hair, scaly skin, and puffiness around her eyes. She appears to be anxious. She is married and responsible for raising three grandchildren (2, 4, and 8 years old). She is employed full time as a college professor and is worried that she may have a serious condition that will compromise her ability to work and care for her grandchildren. She enjoys gardening and reading books. Her vital signs are: T 36° C (36.8° F), BP 102/68, P 68 and regular, and R 12 and unlabored.

Question 1: Identify all the data that the nurse can gather by visually assessing JK.

Question 2: There is a lot of data given in the above case study. List each piece of data and indicate if it is subjective or objective data.

Question 3: Write a minimum of five follow-up questions that the nurse should ask J. K. to obtain additional assessment data.

Answer 1

ANSWERS :

1) Data that can be gathered by visually assessing Judith Kline are:

a) She looks lethargic, tired and anxious.

b) Difficulty in walking more than 10 steps and looks exhausted.

c) Thinning of scalp hair.

d) Scaly skin.

e) Puffiness around her eyes.

2) List each data and indicate if it is subjective data or objective data.

* Subjective data - These are informations from patient's point of view, includes their feelings, perceptions, and concerns. Subjective data is usually obtained by interview.

* Objective data- These are observable and measurable data obtained through observation, physical examination and laboratory and diagnostic testing.

a) Generalized malaise - Subjective data. ( malaise is a general feeling of discomfort, uneasiness or illness for which the person finds difficulty to identity the exact cause).

b) Over whelming feeling of exhaustion that is not relieved with test - subjective data ( exhaustion means a state of extreme tiredness which is felt by the person itself).  

c) Difficulty in walking more than 10 feet- Subjective and objective ( patient self feels the difficulty and can be observed during physical examination by the examiner).

d)Thinning of scalp hair - objective data ( observable )

e) Scaly skin- Objective data.

f) Puffiness around eyes- Objective data.

g) Appears to be anxious - Here it is objective data.(because patient looks or appears to be anxious is a statement observed by the examiner , anxiety can be subjective or objective, when patient says she is anxious it is subjective, but when it is assessed by the examiner it is objective ).

3) Follow up questions that the nurse should ask to obtain additional assessment data include :

a) Family history of thyroid disorders, especially hypothyroidism.

b) Personal history of any thyroid problems and treatment for thyroid problems like surgery, antithyroid medications.

c) History of radiation to head and neck?

d) Any abnormalities in menstrual cycle ( if not menopause )like prolonged bleeding or excessive bleeding?  

e) Feeling any changes in heat and cold tolerance ( hypothyroidism results in cold intolerance )

f) Recent weight gain?

g) Feeling palpitations?