Lab Manual to Accompany Health Assessment in Nursing, Essay Example

History of presenting illness

EA who is a known non-insulin dependent diabetic patient with hypertension, is a patient with a history of cough for one week, which is productive. He experiences chest pain during coughing spells which is centrally placed and non-radiating. It was of sudden onset and has gradually progressed. It is sometimes associated with chest pain of sharp nature and centrally located during the coughing spells.

Client EA also has also been experiencing shortness of breath during the coughing spells and dizziness during any type of exercise or activity that he has to over exert himself.  The cough is also worse while lying down at night and early in the morning and also has a complaint of watery eyes. It’s relieved by sitting upright.

He has uncontrolled sugars due to his stress from job and eating a lot of calories. He therefore reports of occasional acute stomach pains after having eaten a big meal, heartburn is a common ailment occurring roughly three times a month. Patient complains of periodic dizziness and headaches

The patient reports that he has been experiencing an infection on his foot which he described as red with noticeable pus for roughly two months, over the last two toes on the right foot. The infection has a cycle of three months and it recurs after taking antibiotics.

Respiratory system

Inspection

Client EA’s skin appears pale in color with no cyanosis to the skin, lips or chest area. Client EA otherwise has even colored skin tone without any prominent discolorations or lesions to the chest area or face. Nasal flaring is present, Client EA’s trachea is deviated to the left side, there is movement of the chest with inspiration. There is no Kyphosis noted. Client EA spinous process appears straight, and the thorax appears symmetric with the ribs at approximately a 45-degree angle in relation to the spine. The client is sitting in supine position and relaxed but does have some minimal nasal flaring present. Client EA is not using his accessory muscles to assist in breathing.

Palpation

Client EA has no tenderness, pain or unusual sensations upon palpation over the inter-coastal spaces, ribs and chondral junctions. Client EA has a slight Trachea deviation and Symmetrical chest expansions. There is vocal fremitus present. Client EA has no crepitus and Fremitus is symmetric and easily identified in the upper regions of the lungs.

Symmetrical chest expansions

Auscultation

Upon auscultation all breath sounds were within normal limits. There was no adventitious sound present. No wheezing, Crackles noted. The Auscultation voice sounds of Bronchophony was noted to be soft. The Egophony voice sound was also noted to be soft and the Whispered Pectoriloquy was muffled.

Percussion

There was no Hyperresonnance noted across the scapulae or both shoulders, nor the bases of the lungs. There was a flat tone noted over the shoulder and scapulae Client EA excursion was equal and bilateral and measured 5 cm. The level of the diaphragm is higher on the right

Cardiovascular system

Inspection

Upon inspection there are no chest wall deformities. Mucous membranes are not pale and no blue discoloration of the skin and mucous membranes. Capillary refill is less than 3 seconds. Finger clubbing is absent and no splinter hemorrhage in the nail bed. The extremities are warm with no subcutaneous oedema. Regular venous pulse absent

Auscultation

Client EA was in a supine position with upper trunk elevated 30 degrees. The diaphragm of the stethoscope was used for auscultating all areas of the precordium for high pitched sounds and the bell of the stethoscope for low pitched sounds, Aortic,Pulmonic,Erb’s point,Mitral and Tricuspid area.Upon auscultation no blowing or swishing sounds are noted. S1 and s2 heart sounds heard; S2 immediately follows after S1 and is heard the loudest at the base. No murmurs are heard or Gallops noted.

Palpation

Apex beat palpable at the 5^th intercoastal space, No Palpable thrill, Each Carotid artery were palpated one at a time. Each were 2+

Peripheral Vascular

Inspection

Upon inspection the arms are bilaterally symmetric with no edema noted bilaterally. Client EA skin color of hands and arms are a even skin tone bilaterally. No Lymph edema noted. Client’s arms and legs are without any lesions. Clients Hair covers the skin on the legs and arms. No varicosities are noted

Palpation

Client EA skin is warm to touch on the upper and lower extremities, fingers to the fingertips. The capillary beds refill was less than 2 seconds. The radial pulses are bilaterally strong 3+ with a resilent bounce. The client’s ulna pulse was 2+. The client’s brachial pulse was equal bilaterally. The Allen test was performed on the client and pink coloration returned to the palm within 4 seconds. The Femoral pulses were strong and equal bilaterally. The popliteal pulse was palable with normal circulation. The dorsalis pedis pulses are strong bilaterally. The tibial pulse is strong bilaterally. The Homans’ sign was performed. There was no pain or tenderness noted so the test was negative.

Auscultation

The stethoscope was placed over the femoral area to make sure client EA did not have any arterial occlusion.  No bruits noted over the femoral artery.

Lab investigations

1. Chest X-ray- cardiomegally, pleural effusion, tracheal deviation
2. Full haemogram- leukocytosis, low hemoglobin levels
3. Echocardiogram

References

Weber, J., Kelley, J., &Sprengel, A. (2010). Lab manual to accompany health assessment in nursing (4th ed.). Philadelphia: Lippincott.