NR 305 Week 4 Course Project: Milestone # 1: Health History Form
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.
NR 305 Week 4 Discussion Topic: Assessment of Cardiac Status
Esther Jackson is a 56-year-old black female who is 1-day post-op following a left radical mastectomy. ………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.…………..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………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?
NR 305 Week 4 Course Project & Discussion Topic Health Assessment
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