South Florida Community Student Applications Nursing Health Assessment ch 8 case study example attached 1. Read the case study, health history, and physic

South Florida Community Student Applications Nursing Health Assessment ch 8 case study example attached

1. Read the case study, health history, and physical exam.

2. Answer questions, from the text, as indicated for each chapter.

3. In addition to the text questions include the following:

a. Identify the teaching needs and readiness to learn for this client.

b. Identify any cultural factors that influence the care for this client.

c. Document your assessment.

4. Write in complete sentences in narrative form, using one paragraph for each question.

5. Use APA format as follows:

a. Times New Roman, 12 font, 1 inch margins, and double spaced

b. In-text citations to support your decisions.

c. Include Bastable when discussing teaching.

d. References: use your course texts, journals, web sites, etc.

e. Include your last name in the header on the right.

Written Assignment Rubri Case Study Examples
A. Do not include the word puzzles. Complete the questions beginning with the Physical
Assessment.
B. You may choose to state the question then proceed to answer in complete sentences
with citations where needed: (Theses are examples only, they are not complete. Use as
a guide)
1. Because the patient’s daughter is concerned about the possibility of prostate cancer, what
additional assessment is warranted?
To assess for prostate cancer a prostate assessment is warrant. When performing a
rectal/prostate exam, one must note the prostate size, shape, symmetry, consistency,
mobility, nodules, and tenderness (Dillon, 2007, p. 675). Firm, hard, or indurated single
or multiple nodules may be indicative of prostate cancer (Dillon, 2007, p. 675). An
additional screening that can be ordered is a prostate-specific antigen. According to
Dillon (2007) prostate-specific antigen screening can detect tumors before any sign and
symptoms are noted (p. 679). Mr. Liang’s daughter has a legitimate concern because
according to Sanderson, Wigesinha & Jones (2014) prostate cancer was the fourth
leading cause of death in men in 2010 (p.4).
Or simply answer the question without restating it, but include the subject of the statement in
the first sentence.
3.
Mr. Liang’s poor diet suggests that he may have anemia. First, from Mr. Liang’s food
intake record it is evident that there is a void of iron rich food sources which puts him at risk for
anemia. Secondly, his dry skin which may be a result of dehydration which also puts him at risk
for anemia. According to Dillion (2007) a poor oral intake coupled with Mr. Liang’s
unintentional 30 pound weight reduction put him at risk for anemia. He also suffers from fatigue,
Case Study Examples
increased respirations of 20/min, heart murmur, a decreased blood pressure of 102/60 mmHg, a
decreased H/H of 38/13, and a pale conjunctiva which is all indicative of possible anemia.
Examples of nursing diagnosis should look similar to the following:
Nutritional imbalance, less than body requirements is a diagnosis that would relate to him
because …… Carbohydrates should be 50 to 100g per day, or 50 to 60% of the daily caloric
intake. Dillon (2007) explains, there is a six food group pyramid to demonstrate recommended
daily intake…….
Mr. Liang is not getting enough nutrients according to RDA standards. It is
recommended to get 0.8 g/kg per day of protein about 10 to 20% of the daily calorie intake. He is
66.7 kg. He should be having 53g of protein a day. He should consider having protein with every
meal, more water, and a vitamin supplement.
Fluid volume deficit related to decreased oral intake applies to him because he does not
consume much water. He had tea with every meal and 8 oz of juice in the morning. According to
Williams, “A sedentary man should consume 3.7L (125 oz) of total water per day…….
Fatigue related to nutritional deficits is a diagnosis that applies to him because his blood
work shows ……
Or using the numbering system:
6.
Identify any additional nursing diagnosis for Mr. Liang.
Ineffective self-health management related to lack of knowledge about appropriate
nutrition (Lewis et. al., 2011, p. 665).
Activity intolerance related to fatigue and inadequate caloric intake. (Lewis et. al., 2011,
p. 928)
Self-care deficit related to decrease strength and fatigue. (Lewis et. al. 2011, p. 928)
Case Study Examples
Address teaching needs – state this in your first sentence. Include citations from Bastable.
The teaching needs for this patient include ways to incorporate iron and well-balanced diet
planning for all meals. I would also help the patient set up a food journal to monitor what he is
eating to ensure the patient is receiving the right nutrients on a daily basis. I would want to
include a multivitamin and possible iron pills depending on what further testing showed.
Address cultural needs:
Cultural factors that influence the care for this client include that for Chinese Americans,
food is often ate in a specific order (Dillon, 2016). That being said, I would interview the patient
about this concern and possibly address the daughter to see what changes can be made to
accommodate her father. Also in their culture, they believe that food can work as a medicine in
curing people of diseases and affecting their overall strength. Opening the floor for the patient to
explain his eating habits and allowing me to step in and help him make minor adjustments that fit
his culture while nutritionally balancing his needs (Dillon, 2016).
Write out your assessment.
Assessment: Alert and oriented x 3. T. 98.6; P. 99; R. 20/min; BP 102/60 mm Hg; weight 147
lbs; height 5’, 7”. Skin: warm, dry, mild flaking, turgor: fair. PERRLA. Face: symmetric.
Mucous membranes moist, and pink. Respiratory: unlabored, clear. Sinus rhythm, grade 2/6
systolic murmur. Bowel sounds hypoactive. No pain, or palpable masses in abdomen. Full active
/passive ROM. Strength moderate. No edema. Cranial nerves intact. Deep tendon reflexes equal,
+2 throughout.

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