In the assessment of Ms Jones most of the assessment technique was incorporated

In the assessment of ms jones most of the assessment

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heart sounds and percussion of the precordium. In the assessment of Ms. Jones, most of the assessment technique was incorporated into the assessment of thorax/lung. This is done being the parts assessed are co-located with each other and to minimize going back and forth from anterior to posterior. Palpation of the PMI was done after the palpation of the fremitus, and the auscultation of the heart sound was done after auscultating the lung sounds. There were no abnormal findings or irregularities in Ms. Jones cardiovascular assessment. She has no abnormal or extra heart sounds; carotids are equal bilaterally without bruits, no peripheral edemas and capillary refill are less than three seconds. As for cardiovascular intervention, since Ms. Jones is at risk for prehypertension having an SBP >120, we will let her continue her exercise and do it 30 minutes to 1 hour at least three times a week. As for the diet, we will recommend a low sodium diet (Kaplan, 2016) Abdominal assessment: Assessment of the abdomen follows a different order from all the other previous system. The technique is done by inspection first and immediately followed by auscultation. Percussion and palpation are done afterward. In order not to alter the bowel sounds from doing percussion and palpation, inspection and auscultation are done first. Inspection of Ms. Jones abdomen reveal a protuberant abdomen. Ms. Jones obesity contributes to this condition. Obesity makes the abdominal wall thickened and deposits fats in the mesentery and omentum, causing the abdomen protuberant (Jensen & Sabin, 2015 p.593). Auscultation reveals normoactive bowel sound that is present in all quadrants, tympanic throughout to percussion and there are no palpable masses identified through palpation. Other than having a protuberant abdomen, Ms. Jones abdominal assessment is unremarkable.
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PATIENT ANALYSIS AND TEACHING 9 Since Ms. Jones did not report any gastrointestinal problem, we will let her continue her current diet and exercise regimen to continue losing weight. Musculoskeletal. The musculoskeletal assessment follows a technique of inspection and palpation. Ideal assessment of this system includes evaluation of posture, observance of gait, balance, and coordination, palpating extremities for swelling and tenderness, observing ROM and assessing muscle tone, strength, size and symmetry, and inspection of the spine. On Ms. Jones case, some of these techniques were omitted to be not available in the computer software. Inspection, however, did not reveal any deformities or swelling, and she has full ROM in all extremities without complaints of pain with movement. Such assessment is ideal for an average person. The same as for GI intervention, no specific instruction needed for Ms. Jones other than continue her exercise regimen. Neurological: Nurses role in doing the neurological assessment is limited to inspection and palpation (Jensen & Sabin, 2015 p. 667). Techniques that are being used is first assessing the patient LOC, attention, communication and speech to check for aphasia and dysarthria, inspection of pupillary responses, check for abnormal posturing, testing the function of CNS III- VII, evaluation of muscle tone and strength, and check for gait and balance.
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  • Fall '17
  • Diabetes, Blood sugar, Diabetes mellitus type 2

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