Assignment:Screening Tools: Laboratory Tests, Medical Imaging, And Others

Assignment:Screening Tools: Laboratory Tests, Medical Imaging, And Others

Assignment:Screening Tools: Laboratory Tests, Medical Imaging, And Others

Discussion 1

The steps I would take for this patient include taking a comprehensive assessment comprising of patient history, a review of systems (ROS), and a head-to-toe physical examination. In the patient history, I will take a detailed history of the present illness (HPI) that includes more information on the symptoms, including onset, duration, characteristics, associated symptoms, and aggravating/alleviating factors (Harskamp et al., 2019). I will ask the patient if they have taken any medications to relieve the symptoms and what impact they had in alleviating them. In addition, I will inquire about the patient’s chronic illnesses, current medications, allergies, past surgical history, and immunization history. I will also obtain the patient’s family medical history and social history in the patient history.

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In the ROS, a subjective review of each system will be conducted to identify symptoms related to the chief complaint. In the general system, I will ask the patient if he has general symptoms such as weight changes, fever, chills, general body weakness, or fatigue. The respiratory and cardiovascular systems will be vital in the ROS. Thus, under the respiratory system, I will obtain information on the presence of cough, sputum production, hemoptysis, shortness of breath, and wheezing to identify possible underlying respiratory disease (Harskamp et al., 2019). In the cardiovascular system, I will ask if the patient has palpitations, shortness of breath on exertion, orthopnea, edema, or blue discoloration of the lips.

The physical examination will entail assessing body systems related to the chief complaints. I will take vital signs and perform a general patient assessment. In addition, I will assess the respiratory and cardiovascular systems since the patient presents with symptoms related to these systems (Harskamp et al., 2019).

Reference

Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W. A. M., & van Weert, H. C. P. M. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ open, 9(2), e027081. https://doi.org/10.1136/bmjopen-2018-027081

Discussion 2

The steps I would take to assess a patient requesting pain medications will be first to take a subjective history of the pain. This will include onset, location, duration, course of the pain, character, quality of the pain, aggravating, relieving factors, associated symptoms, and severity (Mackintosh-Franklin, 2021). I will ask the patient when the pain started and if it was sudden or increased gradually to help diagnose the problem. I will ask the patient to point out where she perceives the pain and if it is localized, diffuse, or radiating to other body parts. Besides, I will ask the patient about the duration of the pain to identify if it is a chronic or acute pain. Secondly, I will ask the patient if there have been changes in the character of pain over time. In addition, I will ask the patient if the pain has worsened or has remained constant over time since it began. I will also ask about the timing of the pain, that is, the time of the day when the pain worsens.

When obtaining information about the character and quality of the pain, I will ask the patient to describe the pain in their own words. This includes if the pain is sharp, aching, burning, tearing, crushing, stabbing, or throbbing. Besides, I will ask the patient what factors exacerbate the pain and those that relieve it (Mackintosh-Franklin, 2021). Regarding associated symptoms, I will ask the patient about other symptoms they could be experiencing alongside the pain. This will help identify the likely diagnosis and cause of the pain. Symptoms that often occur alongside pain include signs of inflammation like warmth, localized edema, and erythema. The severity of the pain will be assessed using a pain rating scale (Mackintosh-Franklin, 2021). Furthermore, I will conduct a physical exam of the body system associated with the pain to establish the underlying cause, such as inflammation. 

References

Mackintosh-Franklin C. (2021). Recognizing and assessing acute pain. Nursing standard (Royal College of Nursing (Great Britain): 1987), 36(4), 61–66. https://doi.org/10.7748/ns.2020.e11501

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Each discussion board requires a minimum of 250 words with at least 1 peer reviewed source within the past 5 years. APA format required.

Discussion 1: A patient presents with heaviness in their chest and diaphoresis. What steps will you take in providing a proper assessment? Provide a rationale to justify the steps you have chosen.

Discussion 2: A patient calls out on the call system and requests pain medication. We know that patients are to rate their pain on a scale. If the pain is unrelated to the admission diagnosis, what steps will you take in providing a proper assessment? Provide a rationale to justify the steps you have chosen.