Case Assignment 3
Comprehensive Assessment
Comprehensive assessments are crucial in high acuity nursing as it allows nurses to establish a baseline for the patient, determine oxygen supply and demand, provide individualized patient care, and make clinical decisions (House-Kokan, 2012). The components of a comprehensive assessment, including a physical assessment, corroborative diagnostic data, and the patient’s story will be assessed (House-Kokan, 2012).
Physical Assessment
Client’s story. Dorothy is a 30 year old female who is post-op day 2 following surgery for a fractured left tibia and fibula from slipping and falling on a bridge deck. She had been on a bridge threatening to jump, as a “voice in her head” was telling her that she should. Dorothy has a history of schizophrenia and has not been properly taking her medications because she was feeling great and “didn’t need that …show more content…
We would assess for a symmetrical and slightly rounded or convex abdominal shape. We would assess for any distention. We would auscultate all for quadrants for normal bowel sounds. We would palpate the abdomen for soft, non-tender abdomen. We would ask Dorothy when her last BM was.
Genitourinary system. I would ask about her urine output in the last 24 hours noting color and concentration.
Integumentary system. Dorothy looks pale upon initial assessment and is very pale and diaphoretic upon return from PAR. She has a moderate sized incision on her leg covered with a dry dressing. After complaints of pain, her leg is found to be very hot, swollen, and reddened, and sutures appear as if they are about to break. After returning from PAR, her leg appears to be back to normal size. I would assess for motor and sensory function in her leg and compare bilaterally.
Musculoskeletal system. Dorothy was admitted for a broken left tibia and fibula which were repaired with surgery. Assess range of motion in both legs for comparison. Assess her ability to perform