NURS352:

This lesson is focused on the planning of care for a patient. It will be presented in case study format and allow you an opportunity to enhance your knowledge of assessment through the planning of patient care.  This knowledge can be extrapolated to all patients that you care for.  Just jump right in and get started!  Don’t forget to think “outside the box”!

Lesson 4 Objectives

Upon completion of this lesson, you should be able to:

1. Identify abnormal assessment data.
2. Prioritize patient assessment needs.
3. Develop a comprehensive assessment plan.

Lesson Readings and Activities

• By the end of this lesson, make sure you have completed the readings and activities found in the Course Schedule for Lesson 4.

Denzel Armstrong Case Study

Welcome to Dr. Jones’s busy general practice clinic where he sees patients of varying ages.  You are one of three RNs in the clinic and your general duties include assessment, patient education, assistance with minor dressing changes, obtaining routine labs (i.e. urine, blood etc.) to name just a few.  You have been a nurse for five years and feel very comfortable in this environment.  On this day, you have a student nurse, Mary, assigned to work along with you.  Mary is a second-year nursing student in a local university where she is working towards her BSN degree.  Let’s help Mary get started with her first patient, Denzel Armstrong!

Denzel Armstrong is an obese 65-year-old African American male who is new to the clinic.  His previous physician retired 1 year ago and he is now seeking care for his hypertension.  He also has complaints of urinary frequency and nocturia three to four times/night for 2 weeks.  He denies dysuria or fever, but admits to urgency and mildly decreased force of stream.  Denzel reports 8 – 12 bathroom visits per day.  He denied previous problems with urination and states that his only medical problem is high blood pressure, for which he takes hydrochlorthiazide 25 mg/day.

 

Lesson 4 Assessment Plan Assignment

Create your assessment plan document and address the following questions regarding the patient described in the given case.  Be sure to use APA format.

1. After meeting Mary, you both review the information above on Denzel Armstrong together. Your first plan of the day is to complete a thorough assessment on Denzel as this is his first visit at the clinic.  To develop a plan of care, it is important to identify any abnormal data so that it can be clearly addressed.  Based on the information presented in the case study, what is the abnormal data that Denzel presents with?  What is the possible cause of the abnormality?  Please include at least one citation in the cause of each abnormality.
    
2. You and Mary discuss the importance of not only focusing on the areas of abnormality when caring for patients. What are some other assessments that you would want to include in Denzel’s care?  Why?
    
3. You feel that Mary has a good understanding of the importance of assessment and identifying abnormal data. As prioritization of care is a necessity, identify the top three assessment areas (i.e. psychiatric, neurological etc.)  that you will focus on today.  Consider both the abnormal data and the additional assessments that you identified above.  Be sure to provide a clear rationale for each selection.
    
4. Mary is almost ready to provide care for Denzel. Great job!  Your final task is to work with her to develop a thorough assessment plan for your identified top priority.  Provide clear rationale for each aspect of the plan.  Include references as needed.