It is always the responsibility of a nurse to effectively assess the patients in order to fully understand the problems the said patients might be having. During the assessment, a nurse is required to be fully competent with their work by looking out for any signs, symptoms or abnormal behavior a patient might be having in order to fully diagnose the cause of the illness and know how to treat them.
Client.
This assessment is of a 64 year old female named ________ who has been admitted to a hospital with the case of lower lobe pneumonia. In this case, a nurse is required to assess the history of a patient in order to ascertain of the underlying disease or problems. _________ was required to answer some few questions which included the following:.
1. Environment History.
The subjective data of _________ revealed that, she has a history of chain smoking for the past 20 years, has also worked in a paint shop for 15 years and does not cook home meals and spends most of her time indoors watching TV or playing bingo with her friends.
2. Health History.
During the examination, it was revealed that __________ has developed lack of appetite. She also has had a productive cough for the past 12 months. She has also experienced loss of energy as she claims that, she no longer have the energy to perform normal tasks like playing with her grandchildren. She further adds that she has had fever, chills, general weakness and claims to be always tired and lightheaded. Recently, she has also noticed that her phlegm had a bad smell and green in color. She has also experienced shortness of breath in the last few days.
3. Physical Assessment .
During the physical assessment, the nurse notes that, __________ appears older than stated age of 64 years, she is frail, pale and looks quite tired. Her fingers are clubbing, she is quite slim and slightly anxious. Her skin looks quite dry and flaky. Crackles are noted in the lower bases of her lungs with an occasional expiratory wheeze.
