Description
No plagiarism please, include 3 references APA Style, this is a case study that will be posted in discussion board.
You are expected to role play the selected scenario with a family member to gather necessary data to complete the chart. For the person described in the following situations, discuss the developmental/age, socioeconomic, ethical considerations, and cross-cultural considerations that should be considered during the gathering of subjective and objective data, and the provision of health care. Discuss any additional information that might be needed before a judgment or diagnosis can be made.Case Study:
- A. E. is a 35-year-old African American female, and is 5 months pregnant presenting to the office today for a routine prenatal visit. She complains that her neck feels swollen and that she has been feeling nervous and tired. She also complains about the heat, excessive sweating, and how she “can’t seem to get cool during these summer months.” She attributes all these complaints to her pregnancy.
Components of assessment | Subjective Diagnostic Reasoning (list key questions — use PQRSTU pneumonic) | Objective Normal vs. abnormal findings (must note pertinent body systems to be examined) | Differential diagnoses (list 3) Nurses diagnosis (list 1) | List relevant labs and diagnostic studies (if any) |
Normal | Differential | |||
Abnormal Findings | Nurses Diagnosis | |||
Developmental/age considerations:
Socioeconomic considerations:
Cross-cultural considerations:
Ethical considerations:
Additional info needed to formulate actual diagnosis:
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Explanation & Answer
Attached.
Running Head: DIAGNOSTIC REASONING
1
Diagnostic Reasoning
Name
Instructor
Institutional Affiliation
Date
DIAGNOSTIC REASONING
2
1. A. E. is a 35-year-old African American female, and is 5 months pregnant
presenting to the office today for a routine prenatal visit. She complains that her
neck feels swollen and that she has been feeling nervous and tired. She also
complains about the heat, excessive sweating, and how she “can’t seem to get cool
during these summer months.” She attributes all these complaints to her pregnancy.
Components
of
assessment
Weight
Temperature
Pulse
Subjective
Diagnostic Reasoning
(list key questions — use
PQRSTU pneumonic)
Provocation/Palliation:
what were you doing when
the pain began? What
appears to cause the pain?
Are there activities of
position that cause the
pain?
Quality/Quantity: how
can you describe the pain?
Is it burning, sharp,
stabbing, dull, nauseating,
or throbbing?
Region/Radiation: where
is the pain situated? Where
does the pain radiate? Did
it start from one place and
moved to another one?
Objective
Normal vs.
abnormal
findings
(must note
pertinent body
systems to be
examined)
Normal
The heart of the
patient was
examined and the
heart rate was 80
beats per minute
hence normal.
The breast was
examined to
ascertain its size
and
pigmentation.
The breast is
symmetric in size
and has darker
pigmentation on
the areola and
nipple.
After examining
the abdomen of
the patient, it was
found that the
fetal movement
Differential
diagnoses
(list 3)
List relevant
labs and
diagnostic
studies (if any)
Nurses
diagnosis
(list 1)
Differential
Appendicitis
Alphafetoprotein
screening
(AFP)
Hemorrhagic
shock
Amniocentesis
Placenta
previa
Chorionic
villus
sampling
(CVS)
DIAGNOSTIC REASONING
Respiration
Blood
pressure
Severity: in a scale of 0 to
10, 0 being no pain and 10
being worst pain, how
severe is the pain? Does the
pain interfere with your
daily activities? Does it
make you lie down or sit?
Timing: how long does the
pain last: what time does it
start: how often does the
pain occur?
3
is normal.
Varicose veins
are visible on the
patient’s skin.
Ultrasound
Urine protein
and glucose
levels
Vaginal
infection
Fetal
movement
Fetal heart
...
