Physical Examination Of Nursing Diagnosis And The Nursing Process Of Care

1648 WordsOct 14, 20157 Pages
Case Study A 22 year old female has been brought to the emergency room after fainting at home with complaints of flu-like symptoms for the last eight days (GCU, 2010). She has reported vomiting several times a day and having difficulty keeping food or liquids down. She states she has been “taking more than recommended dose of antacids to help with nausea symptoms”. She has become dehydrated, so an IV has been placed and fluids have been started. She also has had an arterial blood gas (ABG) drawn that has shown acid-base deficits. This paper will discuss how a focused history, physical exam, nursing diagnosis and the nursing process of care is important in helping this patient get better. It will also discuss the differences between a complete assessment and a focused assessment. Focus History Focus assessments are the most important part of care planning and delivery for patients which specific complaints. This patient was admitted for flu-like symptoms, nausea, and vomiting related to an unknown source. The etiologies of nausea and vomiting can include iatrogenic, toxic, or infectious causes; gastrointestinal disorders; and central nervous system and/or psychiatric conditions (Jarvis, 2011). A clear definition of the patient 's symptoms must be determined because of the broad possibilities of etiologies. An ordered focus approach to this evaluation is essential. The etiology of most acute nausea and vomiting can be determined from a focused history, physical examination,
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