health assessment

1. Jonah Kotter is a 5-year-old male preschooler who presents to the pediatrician’s office for complaints that his leg “hurts”.

Subjective Data

  • PMH negative
  • Immunizations: Up to date
  • No medications
  • No allergies
  • Pain: 3/5 on pain scale
  • Attends Kindergarten
  • Does not remember injuring leg

Objective Data

  • Vital signs: T 37 degrees Centigrade, P 94, R 18, BP 100/70
  • Lungs: clear
  • Heart rate and rhythm regular
  • Moving all extremities
  • + Range of motion legs and arms
  • Strength 5/5 in all extremities
  1. What other questions should the nurse ask?
  2. What techniques are helpful to incorporate in assessing a patient in this age group?
  3. What are a few of the major differences in the musculoskeletal assessment of a child?
  4. What should be included in the plan of care?
  5. Based on the readings, what is the most likely cause of leg pain for this patient?

 

 

2. Read the case study below and respond to two of the questions below. Make sure you respond to a classmate as well, before the week ends.

Katherine Trembly is a 67-year-old woman who presents to the neurologist’s office after referral from her PCP (primary care provider) for a seizure.

Subjective Data

  • PMH: Seizure, hypertension, anxiety
  • Retired book keeper
  • C/o being “tired”
  • Periods of unresponsiveness to verbal stimuli

Objective Data

  • Vital signs: T 37 degrees Centigrade, P 80, R 18, BP 174/84
  • Lungs: clear
  • O2 Sat = 98%
  • Heart rate regular, + peripheral pulses
  1. What other questions should the nurse ask?
  2. What techniques are helpful to incorporate in assessing a patient in this age group?
  3. What are some of the more common conditions that may cause seizure activity in this age group?
  4. What diagnostic tools will the physician use to diagnose this condition?
  5. What should be included in the plan of care?

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