NR305 Week 4 Discussion: Assessment of Cardiac Status

This week’s graded discussion topic relates to the following Course Outcomes (COs).

CO1 Utilize prior knowledge of theories and principles of nursing and related disciplines to explain expected client behaviors, while differentiating between normal findings, variations, and abnormalities. (PO 1)
CO3 Utilize effective communication when performing a health assessment. (PO 3)

Esther Jackson is a 56-year-old black female who is 1-day post-op following a left radical mastectomy. During morning rounds, the off-going nurse shares with you during bedside report that the patient has been experiencing increased discomfort in her back throughout the night and has required frequent help with repositioning.

She states that the patient was medicated for pain approximately 2 hours ago but is voicing little relief and states that you might want to mention that to the doctor when he rounds later this morning. With the patient appearing to be in no visible distress, you proceed on to the next patient’s room for report.

Approximately 1 hour later, you return to Ms. Jackson’s room with her morning pills and find her slumped over the bedside stand in tears. The patient states, “I don’t know what is wrong, I don’t feel right. My back hurts and I’m just so tired. What is wrong with me?” The patient refuses to take her medications at this time stating that she is starting to feel sick to her stomach.

Just then the nursing assistant comes into the patient’s room to record Ms. Jackson’s vital signs, you take this opportunity to quickly research the patient’s medication record to determine if she has a medication ordered for nausea. Upon return, the nursing assistant hands you the following vital signs: T 37, R 18, and BP 132/54, but states she couldn’t get the patient’s pulse because “it is all over the place.”

Please address the following questions related to the scenario.

What do you suspect is the cause of the patient’s symptoms?
Describe the course of action that you will take to confirm this suspicion and prevent further decline.
What further assessments, lab values, and tests will likely be ordered for this patient and how often? If testing is to be completed more than once, please explain the rationale for doing so.
While you are caring for this patient, how will you ensure that the needs of your other patients are being met?

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Week 4 Assignment: Course Project Milestone 1

Course Project Milestone 1: Health History Guidelines

Purpose

The student will obtain a health history on a willing, nonrelated, adult participant in order to generate written documentation that is clear and accurate. Note: Failing to complete this assignment using an adult participant other than yourself will result in a 20% penalty deduction being applied.

Course Outcomes

This assignment enables the student to meet the following Course Outcomes.

CO #3: Utilize effective communication when performing a health assessment. (PO #3)
CO #4: Identify teaching/learning needs from the health history of an individual. (PO #2)
CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6)

The Course Project Milestone 1: Health History assignment is to be submitted by Sunday, 11:59 p.m. MT at the end of Week 4. Post questions to the Q & A Forum. Contact your instructor if you need additional assistance.

Disclaimer

The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do not need to disclose information that they wish to keep confidential.

If the interviewee decides not to share information, please write, “Does not want to disclose.” If the client fails to disclose answers to several items, you will need to find another client who is willing to share.

You are required to use the linked form for Milestone 1 or you will earn a “0” for the assignment. In addition, assignments that do not follow the current guidelines or use the required form will be evaluated for evidence of an academic integrity violation.

After the due date, there will be no opportunity for revision or resubmission of assignments that have been uploaded to the submission area. It is your responsibility to submit the correct assignment to the correct submission area.

Directions

Find an adult who is not related to you who is willing to let you take a health history.
Download the required NR305_Milestone1_Form (Links to an external site.)Links to an external site.. You will type your answers directly into this Word document. Your paper does not need to follow APA formatting; however, you are expected to be clear in your communication by using correct medical terminology, grammar, and spelling.
Review the examples in Chapter 4 of your textbook to gain insight into how to document the health history. Remember this is a health history, not a physical examination. Avoid words like frequently, improved, increased, decreased, good, poor, normal, or WNL as they may have different meanings for different people. Instead, document the specific data that led you to these conclusions, for example, 3x/day instead of frequently, or consuming four servings of vegetables/day instead of increased vegetable servings.
Save the file by clicking Save as and adding your last name to the file name, for example, NR305_Milestone1_Form_Smith.
Submit the completed form by Sunday, 11:59 p.m. MT at the end of Week 4.

Please post questions in the Q & A Forum so the entire class may view the answers.

NR305 Week 4 Discussion: Assessment of Cardiac Status