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- QUESTION
Zach Miller, MSN, FNP-BC, is on duty at the center today. Zach has 10 years of experience as an RN in the emergency department and urgent care clinic. He has been a family nurse practitioner (FNP-BC) for 5 years. Zach enters the room and introduces himself to Mr. and Mrs. Nguyen. To begin the exam, Zach reviews the information Mr. Nguyen supplied on the admission form and then asks Nam about his family history.
Zach:
Are your parents still living?
Nam:
Yes, they’re both alive. My father is 80 years old and my mother is 76.
Zach:
I’d like to hear a little more about your family history. Tell me about your father’s cancer. How old was he when he was first diagnosed? Has he had treatment?
Nam:
He was probably about 60 when he first found out about it. I know he had some kind of surgery and takes medicines but I don’t know the details. He seems all right though.
Zach:
Your father also has high blood pressure and heart disease. Please tell me a little more about that.
Nam:
My father and mother both have high blood pressure and heart disease. They both take medicines for their blood pressure. My father had a small heart attack about 10 years ago. My mother has never had a heart attack that I know of, but she sometimes has chest pain.Zach:
Your mother also has diabetes?
Nam:
She’s had that for a long time. A lot of people in my family have diabetes, especially on my father’s side—but nobody in my mother’s family. Yet my mother is the one with the diabetes!
Yen:
A lot of people in my family have diabetes too. But so far I’m okay, I think.
Zach:
Have you had a health exam lately, Mrs. Nguyen?
Yen:
Not in about a year, but I’m going to schedule an appointment here.The Nguyens and Zach continue to review the health information. After reviewing the history and discussing current complaints, Zach performs a complete physical exam.
Questions
Caring for the NguyensReview the opening scenario of Nam Nguyen in the front of this book. Imagine you are the clinic nurse at the Family Medicine Center. Based on the information presented in the scenario, work through the following questions:
Question
What type of assessment, comprehensive or focused, is being performed at this clinic visit? Explain your thinking.
Identify the types of data (e.g., subjective/objective, primary/secondary) that have been gathered so far. Give an example of each type.
How might you verify data that Mr. Nguyen provided on the intake sheet?
Based on what you know about Mr. Nguyen, what follow-up assessments would provide useful data to help with the care of Mr. Nguyen? Why would you make these assessments?Rubic grading
Questions are logically answered with feasible and acceptable interventions backed by literature
Responded to assignment questions with knowledge and insight from literature.
| Subject | Nursing | Pages | 3 | Style | APA |
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Answer
Critical Thinking
Skilled and comprehensive history taking is regarded as one of the most fundamental factors in clinical decision making. Medical history of patients and family members provide sufficient information that can be used to make correct clinical decisions (American Nurses Association, 2015). Notably, patient history alone accounts for more than 50 percent o final diagnoses. This essay analyses types of patient assessment and data that have been provided in the case study and how such information is useful in providing patient follow-up assessment to care for the patient.
The type of assessment that has been performed on this patient is comprehensive assessment. This is because even after inquiring the medical history of the patient and his close family members, the nurse has gone ahead to perform complete physical examination which includes head to toe examination. Complete physical exams are routine tests in which healthcare professionals inspect, feel, or listen to different parts of a patient’s body to locate or determine any abnormality. With reference to Mr. Nguyen, there are two major types of data that have been recorded in this case which are subjective and objective data. Examples of subjective data in this case study include the medical history of the patient’s parents that include diabetes and high blood pressure. On the other hand, the objective data is actually the information recorded after the physical examination. An example of objective data in this case may include assessment of head to toe.
A patient’s medical history provides important insight of diagnosis, hence forms one of the most important parts of assessment. It is in this regard that such information must be very accurate. For patients who feed information on their own in the intake sheet, verification of such data is important and should be performed by a nurse. One of the ways of verifying the information is asking the patient similar questions and checking if the response is the same as those in the intake sheet. The nurse can only pick a few questions on the intake sheet in order to ascertain if the information fed by the patient is actually accurate and can be used to make diagnosis (Treas et al., 2018).
Based on the information provided by Mr. Nguyen, follow up assessment of priority is blood sugar level, which is the cause of diabetes. The fact that Mr. Nguyen says that everybody from his father’s side has diabetes insinuates that he is likely to suffer from the same disease. Studies reveal that type two diabetes is inherited. The fact that his father has diabetes, makes him vulnerable to the disease.
References
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American Nurses Association. (2015). Nursing: Scope and standards of practice. Nursesbooks. org. Treas, L. S., Wilkinson, J. M., Barnett, K. L., Smith, M. H., & Treas, L. S. (2018). Basic nursing: Thinking, doing, and caring.
Appendix
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