Focusing on the process of clinical consultation and data gathering
Speciality Masters in Nursing Apply concepts and assessment frameworks discussed in your module reading, describing how you would approach each patient for the comprehensive assessment process. Assume, for the sake of this activity, that the ‘correct answer’ is not necessarily the priority. Focus on the process of clinical consultation and data gathering. You are a nurse practitioner working in a rural community clinic. For each of the following scenarios identify: What framework will you use to gather your data? What are the components of that framework? What is the subjective and objective data presented? What additional data will you need to gather? How would you establish a provisional diagnosis and differential diagnosis? How would you develop a plan agreeable with the patient/client? Scenario One Ella is a 23 year old female will recurrent migraine headaches since childhood. She presents to you with a 14 day history of intermittent throbbing vascular pattern headaches with frequent nausea and vomiting over the past fortnight. Her headaches increase in frequency and intensity with work and family stress and relieved by sleep and cold compresses. There is no papilledema, and no motor or sensory deficits on neurological examination. There is no fever, stiff neck, or focal findings. She is other wise well. Scenario Two Joe is a 45 year old Aboriginal male who presents with a 3 day history of cough productive of green sputum, fever, chills and slight shortness of breath associated with right sided chest pain. Exam is remarkable for a temperature of 38 degree C, BP 142/88, HR 92, RR 18. He is alert, with nil acute distress, but appears tired. On examination, there are crackles noted in the right base on lung exam. No other abnormalities are apparent. He smokes 15 cigarettes daily for the past 10 years and drinks 3-4 mid-strength beers daily.
Apply concepts and assessment frameworks discussed in your module reading, describing how you would approach each patient for the comprehensive assessment process. Assume, for the sake of this activity, that the ‘correct answer’ is not necessarily the priority. Focus on the process of clinical consultation and data gathering. You are a nurse practitioner working in a rural community clinic. For each of the following scenarios identify: What framework will you use to gather your data? What are the components of that framework? What is the subjective and objective data presented? What additional data will you need to gather? How would you establish a provisional diagnosis and differential diagnosis? How would you develop a plan agreeable with the patient/client?
Ella is a 23 year old female will recurrent migraine headaches since childhood. She presents to you with a 14 day history of intermittent throbbing vascular pattern headaches with frequent nausea and vomiting over the past fortnight. Her headaches increase in frequency and intensity with work and family stress and relieved by sleep and cold compresses. There is no papilledema, and no motor or sensory deficits on neurological examination. There is no fever, stiff neck, or focal findings. She is other wise well
Joe is a 45 year old Aboriginal male who presents with a 3 day history of cough productive of green sputum, fever, chills and slight shortness of breath associated with right sided chest pain. Exam is remarkable for a temperature of 38 degree C, BP 142/88, HR 92, RR 18. He is alert, with nil acute distress, but appears tired. On examination, there are crackles noted in the right base on lung exam. No other abnormalities are apparent. He smokes 15 cigarettes daily for the past 10 years and drinks 3-4 mid-strength beers daily.
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