2 What body systems will you assess most thoroughly performing a FOCUSED

2 what body systems will you assess most thoroughly

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2. What body system(s) will you assess most thoroughly performing a FOCUSED assessment based on the primary/priority problem? Identify correlating specific nursing assessments. (NCLEX: Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System: PRIORITY Nursing Assessments: Respiratory fever (possible) , cough , shortness of breath, chills, muscle pain , new loss of taste or smell, vomiting or diarrhea and/or sore throat . Current FOCUSED Nursing Assessment: GENERAL SURVEY: Appears anxious, body tense NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4), generalized weakness HEENT: Head normocephalic with symmetry of all facial features. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic non- productive cough CARDIAC: No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post- tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A- P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Deferred GU: Deferred INTEGUMENTARY: Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no tenting present. 3. What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance:
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Cough, bilateral crackles, diminished aeration, fever Fever and weakened pulmonary function could indicate infection by COVID-19
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4. Interpreting clinical data collected, what problems are possible? Which problem is the PRIORITY? Why? (NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care) Problems: Priority Problem: Rationale: Decreased tissue perfusion ineffective airway clearance Ineffective Airway Clearance PT is demonstrating decreased o2 saturation and bilateral crackles. If airway is not addressed, PT will likely develop secondary problems like infection or hypoxia related damage 5. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care) Nursing PRIORITY: Ineffective Airway Clearance GOAL of Care: Maintain airway patency, demonstrate improved oxygen exchange Nursing Interventions: Rationale: Expected Outcome: Assist client in airway clearance techniques Monitor respirations and breath sounds Observe for signs/symptoms of infection To improve respiratory function and gas exchange To monitor for respiratory distress or accumulation of secretions
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