Focused Assessment of the Lungs and Thorax Essay Example Paper

Focused Assessment of the Lungs and Thorax Essay Example Paper

First, gather data about the patient’s history as it is essential to obtain before you begin your examination. According to Kelsey Young, she was at the emergency department the day before visiting the clinic for having an episode of breathing difficulty. Next is to conduct an interview and ask relevant questions regarding the complaint of the patient. As verbalized by Kelsey, “she was at school and was coughing and couldn’t stop, and then her chest felt tight and she felt like she could not breathe right”. As with her history, she said that it never happened before. Mrs. Young also validates that Kelsey does experience signs and symptoms such as cough in the morning, frequent colds, chest pain, and difficulty breathing. As for other relevant information about the symptoms, the patient pointed on her chest area for the exact location where her breathing feels bad and described that “her chest hurts and her breathing feels ‘funny’, not like normal” and her coughing “makes her chest feel funny too”. For the duration, it has been occurring for a year or so, according to Mrs. Young. Focused Assessment of the Lungs and Thorax Essay Example Paper

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Next is looking for aggravating factors that precipitate the symptoms (Tarasidis & Wilson, 2015). According to the patient, her breathing feels worse when she runs around, coughs and sneezes a lot when she plays with her new kittens, and sometimes experiences chest pain when her father smokes. Whenever she experiences these signs and symptoms, she does nothing as it usually just gets better.

Lastly, ask for any other background information such as family history and their occupational history as this may help get a better diagnosis for the patient.

You may now proceed with your physical exam by using a stethoscope to listen to the patient’s breathing. Expiratory wheezes have been detected upon auscultation with normal findings upon thorax examination. After ruling out other causes, Kelsey is diagnosed with asthma Focused Assessment of the Lungs and Thorax Essay Example Paper

Plan of Care

Nursing Diagnosis #1: Inefficient respiratory pattern caused by bronchial tube swelling and spasm in reaction to inhaled allergens, as seen by coughing and trouble breathing

Nursing interventions:

• Listening to breath sounds and unusual noises like wheezes and stridor. This is because unusual sounds might signal a deteriorating condition or the onset of new problems, like pneumonia (Martin, 2020).
• Encouraging the patient to exhale with their lips pursed. Pursed lip exhalation optimizes breathing patterns by enabling fresh air to enter the lungs while removing old air.

Nursing Diagnosis #2: Activity intolerance as a result of an airway condition, as shown by fatigue and an insufficient time to play

Nursing interventions: 

• During rest time, encourage activities such as silent play, reading, watching tv, and playing games. This prevents changes in respiratory status and energy loss caused by excess exertion (Martin, 2020).
• Educate parents and children about the need of conserving energy and avoiding weariness. This increases awareness of the impact of activities on breathing and the importance of rest to avoid exhaustion.

 Patient Education

In this case, encouraging her dad to stop smoking is very beneficial to Kelsey. As for Kelsey, talking about removing the cats at home will be quite hard for her, but giving her options to choose another pet safer for her would be the best option.

The asthma teaching plan for Kelsey should include the following:

1. The importance of regularly taking her medications and inhalers.
2. Providing options to Kelsey in choosing a new pet instead of a cat.
3. Proper use of the inhaler and knowing when to replace it before being completely consumed.
4. Avoiding activities, food and things that trigger the attack. It is highly advisable to coordinate with the school officials about Kelsey’s condition to limit her physical activities at school, especially during PE class.

The best way to help Kelsey learn all these is by reinforcement and letting her be involved in their care itself (Boulet et al., 2015). For example, in teaching how to use an inhaler, there are many fun and child-friendly videos online that can be utilized. Activity books that discuss asthma are also readily available online or in bookstores. If the child can adequately demonstrate the use of inhalers and answer your follow up questions, this is a good indicator that the child could understand the health teaching well. Monitoring the occurrence of asthma after the client education is also vital because it will help the healthcare providers know if the medical and educational intervention is effective. That said, regular follow up’s should also be made. Focused Assessment of the Lungs and Thorax Essay Example Paper

How to Document Findings in the Medical Records

When documenting assessments and findings in a medical record, it should consist of a complete recording of a patient’s clinical data, demographics, medical history, diagnoses, medications being taken, allergies, and others that are required to be in a medical record to have systematic documentation of the patient’s condition (Mathioudakis et al., 2016). A medical record should also contain medical notes done by the doctor, nurse, and other healthcare members who attended to the patient’s situation. It should include records about the patient’s medical history since birth. The documentation of findings in the medical records takes the following format:

• Patient’s information: It should consist of the patient’s complete name, contact number, address, patient’s ID number, birth date, status, gender, marital status, race, language, name of the provider, location of care, MRN or the medical record number and all the necessary information needed. A nurse practitioner should also ask and document if there were medical history diagnoses, medications that the patient is taking, allergies, and vaccinations.
• Chief complaint:this includes a statement that the patient is coughing and could not breathe right.
• History of the present illness (HPI):this should be documented in detail.
• Review of systems: this includes all pertinent systems that are related to the patient’s health problem.The review of systems is like an inventory of the patient’s body systems to determine the signs and symptoms that the patient is experiencing. If the patient denies it, you should also document it precisely.
• Vital signs: this consists of the height, weight, temperature and site taken, blood pressure, respiratory rate and pulse rate.
• Physical examination: this includesthe actual examination findings, which should also be system by system. Normal and abnormal assessments should be documented. If there is no problem with a particular body system, it should also be noted.
• Impression: This is the summary of findings after the thorough assessment.
• Plan: This consists of the treatments, tests and medications ordered by the physician, follow-up or return visit schedules if necessary and the disposition or the patient be sent after the ER Focused Assessment of the Lungs and Thorax Essay Example Paper

References

Boulet, L., Boulay, M., Gauthier, G., Battisti, L., Chabot, V., Beauchesne, M., Villeneuve, D., & Côté, P. (2015). Benefits of an asthma education program provided at primary care sites on asthma outcomes. Respiratory Medicine, 109(8), 991-1000. https://doi.org/10.1016/j.rmed.2015.05.004

Martin, P. (2020, January 9). Nursing diagnosis for asthma: 8 nursing care plans. Nurseslabs. https://nurseslabs.com/asthma-nursing-care-plans/

Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe, 12(4), 369-373. https://doi.org/10.1183/20734735.018016

Tarasidis, G. S., & Wilson, K. F. (2015). Diagnosis of asthma: Clinical assessment. International Forum of Allergy & Rhinology, 5(S1), S23-S26. https://doi.org/10.1002/alr.21518

Focused Assessment of the Lung and Thorax

Objectives

• Develop a plan of care for the lung and thorax system
• Demonstrate documentation of the lung and thorax assessment findings
• Explain how to conduct a physical assessment of the lung and thorax

Assignment Overview

In this writing assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client Focused Assessment of the Lungs and Thorax Essay Example Paper

Deliverables

A three-page (750-word) paper

Step 1

Review the case scenario.

Kelsey Young is a seven-year-old African American girl who presents to the clinic today with her mother, Angie Young, as a follow-up to a visit to the emergency department after she had an episode of breathing difficulty the day before.

• Onset: You ask Kelsey to describe what happened that brought her to the ER yesterday. She tells you she was at school and was coughing and couldn’t stop, and then her chest felt really tight and she felt like she couldn’t breathe right. She says that she got really scared, and the school nurse called an ambulance and her mom. You asked Kelsey if that ever happened before and she says no. You ask Mrs. Young if Kelsey has had any other respiratory or breathing problems. She tells you Kelsey always has a cough in the morning, but it seems to get better, and she never complains about it at school. She does get frequent colds, though. You ask Kelsey and Mrs. Young if she has noticed Kelsey has difficulty breathing or complains of chest pain. Kelsey tells you sometimes at recess she has trouble keeping up with the other kids because her chest hurts, and it is hard to breathe. Mrs. Young validates that she has noticed this as well.
• Location: You ask Kelsey to show you where her breathing feels bad, and she points to her chest area Focused Assessment of the Lungs and Thorax Essay Example Paper
• Duration: You ask Mrs. Young to describe how long the coughing and shortness of breath has been occurring, and she tells you for about a year or so.
• Characteristics: You ask Kelsey to describe what it feels like when she has trouble breathing or coughing. She tells you that her chest hurts and her breathing feels “funny,” not like normal. She tells you her coughing makes her chest feel funny too.
• Aggravating factors: You ask Kelsey to tell you what makes her breathing feel worse. She tells you it gets worse when she runs around. She also tells you she coughs and sneezes a lot when she plays with her new kittens, Chico and Kiekie. She also tells you her chest sometimes hurts when “daddy smokes.”
• Alleviating factors: You ask Kelsey what makes her breathing better and she tells you she’s not really sure, it just usually gets better.
• Other background information: Kelsey is one of two children, and she has a younger brother, Marcus. Her father is an accountant and is a smoker. He has tried to quit but has been unsuccessful. Her mother is a stay-at-home mother and is very involved with her children. Kelsey loves to read, watch movies about animals, and play with her cats.
  

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You perform the following assessment: Focused Assessment of the Lungs and Thorax Essay Example Paper

• Lungs: Expiratory wheezes, otherwise clear
• Thorax: Normal findings upon exam

Diagnosis and treatment: After ruling out other causes, Kelsey is diagnosed with asthma. She is placed on inhaled corticosteroids, an albuterol rescue inhaler, and Claritin for her allergies. Mrs. Young is advised to consider removing the kittens from the house and to have Mr. Young stop smoking in the house.

Step 2

Provide answers for each item below.

You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills. In your paper, discuss the following items:

• Write a detailed explanation describing what you would say to the student, explaining the assessment conducted and the findings. Discuss the thorax assessment you performed and any additional assessments you would perform. What are other factors related to the probable diagnosis you would be concerned about with this client?
• Explain how you would document your findings in the medical record.
• Develop your plan of care. Identify one to two nursing diagnoses and one to two nursing interventions related to those diagnoses. The interventions need to be evidence based. Cite the references used in your plan in correct format.
• Identify what client education (including creating an asthma action plan for the client) should be done for Kelsey, given her background and presenting illness. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention Focused Assessment of the Lungs and Thorax Essay Example Paper

Focused Assessment of the Lung and Thorax Objectives • Develop a plan of care for the lung and thorax system • Demonstrate documentation of the lung and thorax assessment findings • Explain how to conduct a physical assessment of the lung and thorax Assignment Overview In this writing assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client. Deliverables A three-page (750-word) paper Step 1 Review the case scenario. Kelsey Young is a seven-year-old African American girl who presents to the clinic today with her mother, Angie Young, as a follow-up to a visit to the emergency department after she had an episode of breathing difficulty the day before. • Onset: You ask Kelsey to describe what happened that brought her to the ER yesterday. She tells you she was at school and was coughing and couldn’t stop, and then her chest felt really tight and she felt like she couldn’t breathe right. She says that she got really scared, and the school nurse called an ambulance and her mom. You asked Kelsey if that ever happened before and she says no. You ask Mrs. Young if Kelsey has had any other respiratory or breathing problems. She tells you Kelsey always has a cough in the morning, but it seems to get better, and she never complains about it at school. She does get frequent colds, though. You ask Kelsey and Mrs. Young if she has noticed Kelsey has difficulty breathing or complains of chest pain. Kelsey tells you sometimes at recess she has trouble keeping up with the other kids because her chest hurts, and it is hard to breathe. Mrs. Young validates that she has noticed this as well. • Location: You ask Kelsey to show you where her breathing feels bad, and she points to her chest area. • Duration: You ask Mrs. Young to describe how long the coughing and shortness of breath has been occurring, and she tells you for about a year or so. • Characteristics: You ask Kelsey to describe what it feels like when she has trouble breathing or coughing. She tells you that her chest hurts and her breathing feels “funny,” not like normal. She tells you her coughing makes her chest feel funny too. • Aggravating factors: You ask Kelsey to tell you what makes her breathing feel worse. She tells you it gets worse when she runs around. She also tells you she coughs and sneezes a lot when she plays with her new kittens, Chico and Kiekie. She also tells you her chest sometimes hurts when “daddy smokes.” • Alleviating factors: You ask Kelsey what makes her breathing better and she tells you she’s not really sure, it just usually gets better. • Other background information: Kelsey is one of two children, and she has a younger brother, Marcus. Her father is an accountant and is a smoker. He has tried to quit but has been unsuccessful. Her mother is a stay-at-home mother and is very involved with her children. Kelsey loves to read, watch movies about animals, and play with her cats. You perform the following assessment: • Lungs: Expiratory wheezes, otherwise clear • Thorax: Normal findings upon exam Diagnosis and treatment: After ruling out other causes, Kelsey is diagnosed with asthma. She is placed on inhaled corticosteroids, an albuterol rescue inhaler, and Claritin for her allergies. Mrs. Young is advised to consider removing the kittens from the house and to have Mr. Young stop smoking in the house. Step 2 Provide answers for each item below. You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills. In your paper, discuss the following items: • Write a detailed explanation describing what you would say to the student, explaining the assessment conducted and the findings. Discuss the thorax assessment you performed and any additional assessments you would perform. What are other factors related to the probable diagnosis you would be concerned about with this client? • Explain how you would document your findings in the medical record. • Develop your plan of care. Identify one to two nursing diagnoses and one to two nursing interventions related to those diagnoses. The interventions need to be evidence based. Cite the references used in your plan in correct format. • Identify what client education (including creating an asthma action plan for the client) should be done for Kelsey, given her background and presenting illness. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention.