Case Study: Cardiac component

Case Study: Cardiac component
Case Study: Cardiac component
Here is an example of documentation for your competencies. Include all parts on one word document for that week. This only includes general and thorax as an example. You would also include the cardiac component. This is a narrative documentation. I am looking for your to paint a picture of your assessment in a concise and thorough manner. Be sure to utilize the correct terminology. Remember that in documentation you do not need full sentences, so do not write….patient is alert and oriented……
You are required to demonstrate competency in the physical assessment techniques. You also are required to accurately document your physical assessment findings. These two requirements are worth 70% of your grade. You will find the specific guidelines for these two requirements on the course blackboard. You will be required to video record yourself performing the various assessments and submitting them on blackboard.
Question 2
As in prior discussion forum Your initial post can be to either option #1 or option #2 However, the group must split so that half the group does #1 and the other half does #2
Option #1 – SP is a 3-year-old female toddler who presents to the pediatrician’s office for a yearly well visit The child complains that her leg hurts Subjective data includes: PMH of otitis media; up to date immunizations; no medications; no allergies; pain is 3/5 on pain scale; attends preschool and unable to recall injuring leg Objective data includes: vital signs – T 986, P 92, R 18, B/P 100/70 Lungs clear in all anterior and posterior fields, heart rate and rhythm regular, moving all extremities; full ROM in legs and arms, and strength 5/5 in all extremities
1 What other question should the nurse ask?
2 What other techniques are helpful to incorporate in assessing a patient in this age group?
3 What other assessments should the nurse make for this clinical presentation?
4 What are a few of the major differences in the musculoskeletal assessment of a child?
5 Based on the readings what is the most likely cause of leg pain for this patient?
Option #2 – Discuss the developmental, age, socioeconomic, and cross-cultural considerations that should be considered during the gathering of the subjective and objective data and the provision of healthcare Discuss the findings presented Is there additional information / assessments you would like to know prior to making a clinical judgment? Also, relate the anatomic area of injury or physiologic alteration to the neurologic source of that condition
JL had a CVA within the past week JL is easily frustrated, anxious, and fearful, and her speech is slurred She needs verbal cuing for any task she is asked to carry out She eats only food on the left side of the tray and responds only when approached from the left side

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