Focus assessment

884 WordsJul 1, 20144 Pages
Focus assessment NUR-645E Griselda Richard June 18, 2014 Focus Assessment The purpose of this paper is to document a focused history, physical exam, nursing diagnoses, and nursing process of a case study about a 22-year-old woman that reports as chief complaint : feeling “sick with the flu” for the past 8 days. History of present illness : vomiting several times every day, having difficulty keeping liquids or…show more content…
Also check for Kussmaul respirations as all this are signs and symptoms of metabolic acidosis. Assess arterial blood gases and BUN/ creatinine ratio: Normal ratio is 10:1 to 15:1. Ratios greater than 20:1 are associated with dehydration. Assess for changes in hemoglobin, hematocrit and white blood cell count: all levels may be elevated due to hemoconcentration. Assess the effects of IV therapy: by assessing VS and lab work. Administer IV therapy as ordered: usually starting with normal saline (0.9%) to correct the circulatory volume deficit and fallowed by the solution needed according to results of lab work. The patient need, ability and willingness to learn should be evaluated along with his or her support system. (Pearson 2012) Patient assessment and care are the most important parts of nursing education. The development of these skills makes possible for the nurse and other health care professionals to quickly assess and adequately determine a plan of care for any particular patient. The nurse should be able to collect data with the purpose of identifying any deviation from baseline. To identify the patients coping mechanisms, strengths and resources. As well as any factor or
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