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Assessment Focus

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Focussed Assessment
In the given case study patient has persistence vomiting for eight days and she took
Antaacids to relieve the symptoms. She is dehydrated, and her lab results shows she has metabolic alkalosis.
In focused assessment, detailed nursing assessment of particular body system(s) connected to the current problem is required. One or more body system may be involved.Nausea and vomiting can ocurr due to different reasons like food poisoning,chloecystitis or intestinal obstruction..For the patient with vomitting,intially the health care provider need to pay attention to signs of dehydration. Like assessing monitoring blood pressure and observing for hypotension, skin turgour and mucous membranes changes (McCance, Huether, Brashers, & Neal, 2014). General Assessment: Patient had dark circles under the eyes. She looked worn out. She was feeling anxious. Her energy level was very low. She was speaking very slowly. Abdominal Examination: Abdomen is soft to touch. Patient has some epigastric pain. Bowel sounds are decreased.No bloating or acidity. Signs of hypo-motility may indicate an increased risk for nausea and vomiting. Cardiovascular system: Patient is hypotensive with tachycardia. No heart regurgitation or murmur. Heart rhytm is regular. Patient is feeling tired and dizzy.
Pulmonary system: Patient is in metabolic alkalosis. Respirations rate is low 12 breaths per minute. Patient is taking deep regular breaths. Lungs are clear to ausculation. She has no shortness of breath or wheezing.No sign or symptom of any aspiration.
Integumentary System: Patient‘s skin was pale and flaccid. Patient had dark circles under the eyes. Oral mucosa was dry with some swelling of tounge.
Urinary System: Patient’s urine out put is decreasing. No urine out put in last 12 hours. Nursing Diagnosis for Vomiting
- Fluid Volume Deficit related to the feeling of nausea and vomiting Goal: Maintain the balance of fluid volume. Outcomes: The client does not nausea and vomiting.
Intervention:
1. Monitor vital signs. 2. Monitor intake output and vital signs, and vital signs, blood pressure orthostatic. 3. .Monitor intake and output and urine concentration.
-Metabolic Akalosis due to Nausea /Vomiting
Goal: Patients expressed no nausea and vomiting and normal blood Ph.
Interventions:
1. Give anti- emetic.
2. Sodium chloride infusion is required to expand fluid volume along with potassium chloride
3. Oral care to reduce emesis and increased comfort. 4. Odor-free environment, clean, so it does not cause nausea
- Risk for aspiration related to frequent vomiting. Goal: Airway and lung sounds are clear.
Iintervention : 1. Assess whether the patient is in the risk for aspiration. 2. Place the patient in a position to prevent aspiration.
-Knowledge deficit about medications
Goal: The client will express an understanding of dosage, purpose and side effects of medications.
Intervention: Consistent approach to assess, teach and evaluate patient’s knowledge and abilities with medications.

Focused Assessment versus Complete Assessment Assessment is a fundamental constituent of nursing practice, required for organizing and providing patient and family oriented care.Focused Assessment is a thorough nursing evaluation of particular body system(s) relating to the presenting problem or other current concern(s) is required. It may include one or more body system.Complete health assessment is performed to assess a client's medical status.It helps to recognize functional health patterns that are problematic and to deliver indepth comprehensive data base, which is critical for determining client's health status changes in subsequent assessments. It serve as a baseline (Comprehensive Health Assessments, n.d.). Comprehensive Assessment During comprehensive health assessment, healthcare provider observes and assess the whole body by a complete physical (head-to-toe) examination. The initial evaluation is usaually comprehensive assessment; it provide information and data to find the nature of the problem and prepares the way for the following assessment stages. A complete history and physical examination can often reveal the problem. A detailed history of symptoms can provide clues to a diagnosis The first evaluation is going to be much more thorough than the other assessments used by nurses. It may include obtaining a patient's medical history, a physical exam, or preparing a psychosocial evaluation for a mental health patient. Other components may include getting a patient's vital signs and taking subjective statements from the patient, as well as double-checking the subjective symptoms with the objective signs of the condition. A “comprehensive” examination reviews most of the patient’ medical, social and family history if not all history. It also include a head to toe physical examination (Bickley, 2009). Comprehensive assessment is appropriate for new patient in the hospital or office. Mostly it is for the first visit. It provides fundamental and personalized knowledge about the patient and strengthens the clinician and patient relationship. Complete assessment helps to identify or rule out physical causes related to patient concerns, and it provides baseline for future evaluations. During comprehensive assessment health care, provider can gain patient confidence, and it offers a platform for health promotion through education and counselling. Complete physical assessment helps health care provider to develop proficiency in essential skills for physical examination. Documentation of a full evaluation include detailed information about patient like fundamental and personalized knowledge regarding the patient, not just only a physical assessment (Bickley, 2009). It is usually done in one of two circumstances: 1) the inpatient admission history and physical examination. 2) In a doctor’s office or clinic when the patient establishes care or gets a periodic complete history and physical exam checkup or a periodic health maintenance examination. Most comprehensive history and physical examinations take between 30 to 60 minutes to complete (UW Medicine, 2015). Focused Assessment A focused health assessment is problem-oriented and system oriented. The focused assessment is the phase in which the problem is uncovered and treated. Due to the importance of vital signs and their ever-changing nature, they are always monitored during all parts of the assessment. Focused assessment’s goal is to diagnose the problem and treat the patient in order to stabilize the patient condition. Focused assessments may also include X-rays or other types of tests. . Foccused assessment is a detailed nursing assessment of a particular body system(s) relating to the presenting problem or other current concern. It may involve one or more body system. A focused assessment collects data about a problem that has already been identified. This type of evaluation has a narrower scope and shorter period than full evaluation. In targeted assessment, nurse determine whether the problem still exits and whether the status of problem has changed(improved, worsened or resolved).Like in intensive care nurses perform focused assessment of a system more frequently(www.copemanhealthcare.com). The “focused” history should explore and characterize the patient’s primary health concern but must also include critical background history that is necessary to put the patient in context (UW Medicine, 2015). Focused assessment is appropriate for established patients. It is done for routine office care visit or patient with urgent care concerns. In the focused evaluation, the healthcare provider addresses primary concerns or symptoms at that time. Assessment is restricted to a particular body system. Healthcare providers need to remain focused on the concerned system or problem to do a precise and careful assessment. Documentation of a focused assessment should include accurate and precise documentation of the particular health problem or event (Bickley, 2009). . A “focused” physical examination consists of selected items that help confirm or refute physical findings related to the presenting health issue.A “focused” history and examination is one that can be taken in 8 to 14 minutes that addresses the patient’s presenting health issue (UW Medicine, 2015).

References

Bickley, L. S. (2009). Bates'guide to physical examination and history taking. Philadelphia: Wolters Kluwer/Lipponcott Williams&Wilkins.
Comprehensive Health Assessments . (n.d.). Retrieved from www.copemanhealthcare.com: http://www.copemanhealthcare.com/health-services/health-assessments/#sthash.oYwU5Ars.dpuf
McCance, K. L., Huether, S. E., B. V., & Neal, R. (2014). The biological basis for disease in adults and children. Canada: Elsvier.
P, M. (2014, December 2014). Health History.
UW Medicine. (2015). Focused History or Exam. Retrieved from http://www.uwmedicine.org/education/md-program/current-students/curriculum/osce/focused-history-exam

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