Assignment Description: Learning to associate symptoms and complaints with disease processes helps the nurse clinician hone assessment skills and provide better care to patients. Assignment Directions: Complete the following table on two patients. Reflections on the Chief Complaint Worksheet: As a result of this activity, I have learned how to: I have learned how to properly assess my patients by doing specific system assessments based on their diagnosis.
I have also learned how to ask questions in order to further investigate the patient’s problem and what could be happening as a result. This activity shows that I have more to learn about: I have more to learn about what interventions should be prioritized and how to incorporate all interventions as well as medications more efficiently. This activity shows my growth because: This activity shows my growth because I was able to figure out the different needs of my patients and what to teach them while they are in my care. This activity helped me because I was also able to formulate teaching plans for when my patients become discharged.
I believe this is important because teaching patients is my responsibility as a nurse and I want to be able to reach out to my patients and make sure they go home with all the tools they need to improve their health. Chief Complaint Worksheet Grading Rubric Description Points Percentage Points Earned Comments Accurately obtains information on two patients 16/40% Completes assessments and answers questions regarding emergency department visit 16/40% Completes reflections on tool 8/20% Total 40/100% 1. Indicate Patient Age, Gender, Final Diagnosis Patient One Patient Two 59 year old male with Hep C, cirrhosis, polysubstance abuse, and enterocolitis.
44 year old male with sepsis secondary to pleural effusion, TB in lungs. 2. What was the “chief complaint” that prompted the patient to seek medical attention? Patient One Patient was found on the ground lying in his own stool. Patient Two Severe chest pain (pleuritic pain) radiating to back on deep inspiration. 3. What signs and symptoms were noted on arrival at the hospital? Patient One Anxiety, fever, chills, abdominal pain, back pain, nausea, and confusion.
Patient Two Vomiting, chest pain, fever, fatigue, and weakness. 4. What diagnostic tests were completed relative to these signs and symptoms? Why were they ordered? Patient One CBC with diff. for infection, drug screen for current use of substance, liver tests for symptoms of cirrhosis, CT of pelvis and abdomen with contrast for symptoms of pain. Patient Two Chest CT with contrast for chest pain (lung pain) and CBC with diff. for infection. 5. What medical treatments/interventions were implemented to treat these signs and symptoms (include medications)? Patient One Flagyl, Xanax, Morphine, Levofloxacin, Zofran.
Patient Two Insulin for diabetes, Metoclopramide, Isonazid, Moxifloxacin, rifampin, Lisinopril, Potassium Chloride. 6. What nursing interventions were implemented to treat these signs and symptoms? Why were these interventions implemented? Were they successful? Patient One Bed alarm for fall risk due to confusion from liver and infection. Patient continued to try to get out of bed. Orientation of patient because of confusion. Patient was more pleasant the more we orientated but patient has a history of mental disorders. Patient Two Airborne precautions because of TB/lung infection.
Precautions were successful. Chest tube inserted for removal of fluid and to relive pain. Patient continued to have pain after chest tube removal. Diabetic diet in order to control blood glucose. Patient continued to have readings in the 200’s. 7. What teaching needs to be completed regarding the above? Patient One Patient needs to be re-oriented in order to keep him in a pleasant mood. . Patient was very dependent on pain medication and needs to be taught about other methods for pain management, such as watching TV, changing positions, calling friends and family, and eating properly.
Patient Two Patient needs to be consulted about diet and how to control blood glucose levels. 8. What teaching needs to be completed if the patient is discharged home? Patient One Patient needs to remember or write down methods for controlling pain. Patient also needs to be taught to avoid drugs and to eat properly. Patient Two Patient needs to be reminded to check his blood glucose often and write down results. Patient also needs to be taught about medication compliance so that the TB or lung infection does not return. 9. Visit each patient and perform full assessment of the patient and the patient’s environment.
Write a narrative of your assessment; include safety concerns. Patient One Patient’s GCS is 15. Patient’s skin has ecchymosis. Patient is missing teeth. Patient is confused and has anxiety. Patient’s abdomen is rounded and he is experiencing pain. Patient has PERRLA and vitals are BP 132/74, HR 69, temp. 97. 7 F, O2 is 98, and respirations are 18. Patient has no irregular breath sounds and his abdominal sounds are hypoactive. Patient has equal pulses in all extremities and has full range of motion in all extremities. Patient is confused Patient Two Patient’s GCS is 15.
Patient’s skin is clear and tan with a scar on the left posterior scapula. Patient has missing teeth and is underweight. Patient’s vitals are BP 169/77, HR 88, temp. 97. 3, O2 100, respirations 18. Patient has diminished right lower breath sounds and normal active bowel sounds. Patient’s pulses are equal in all extremities and patient is full weight bearing with full range of motion. and is a fall risk. Last bowel movement was the morning prior and his urine is yellow and clear. Patient’s last bowel movement was in the morning and patient’s urine is slightly orange and clear.