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Nursing Professionalism, Case Study Example

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Case Study

Introduction

Evaluating this patient requires the collection of subjective data, including the determination of the level of pain using a scale of 1 to 10; ask the patient how long the pain has occurred; ask the patient if the pain has interrupted his normal activities, including sleep; and ask the patient if the pain is localized to one specific area or if it expands to other areas (Dains et.al, 2012). This data will determine a potential diagnosis and a possible treatment plan.

Analysis

Other subjective data that is relevant for this patient includes any recent changes in diet or exercise that could have an impact on his health and that have caused pain, vomiting, or other forms of discomfort (Richardson, 2011). In addition, changes in stool that have occurred recently should be explored, along with any blood that has been spotted in urine (Richardson, 2011). Furthermore, subjective data should also including other non-abdominal symptoms, such as sore throat, cough, chills, congestion, and runny nose, among other symptoms (Richardson, 2011). The patient’s mother should also be asked about any medications that he has been taking so that any possible interactions or other impacts might be explored (Bickley, 2013). The mother should also be questioned regarding the patient’s lack of circumcision because this may demonstrate a pattern of similar symptoms that might have occurred in the past (Bickley, 2013).

Conclusion

Finally, subjective data should include any other potential concerns that the patient has had in recent weeks that might play a role in his current state and the symptoms that he is experiencing (Swartz, 2010). These questions will provide additional insight into the patient’s possible diagnosis and the development of a treatment plan that will have a positive impact on alleviating these symptoms over a period of time (Swartz, 2010).

References

Bickley, L.S. (2013). Bates’ guide to physical examination and history taking, 11th edition. Lippincott, Williams, & Wilkens.

Dains, J.E., Baumann, L.C., and Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care, 4th edition. Elsevier Mosby.

Richardson, B.E. (2011). Pediatric primary care: practice guidelines for nurses. Jones & Bartlett Publishers.

Swartz, M.H. (2010). Textbook of physical diagnosis: history and examination. Saunders.

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