Assessment 2 Guide
Mrs Jane Johnston is a 60 year old female who presented with acute abdominal pain. The pain came on yesterday after eating dinner.
Observations on presentation-
T 37.8, PR 96, RR 28, BP 90/60 Patient is complaining of sudden onset upper abdominal pain, that radiates through to the back and is associated with nausea and vomiting. GCS 15. Past history- appendicectomy at age 20. Does not drink alcohol.
Lipase is elevated at 2000. Mrs Johnson has been given a diagnosis of pancreatitis.
Under each of these heading assess YOUR PATIENT from the chosen case studies. You do not know the medical diagnosis of your patient at this point- this is an assessment. However you will write the assessment to fit the case study.
Using a systems assessment do a full assessment of your patient. DO not include the primary survey. This is just the secondary assessment of your patient.
Allocate approx 800 words for this section. This will include detail based on YOUR PATIENT.
For example under CVS- Mr Smith was pale and sweaty. This would fit for the case study of the MI.
Use the following headings:
Central Nervous System- CNS
Cardio vascular system- CVS
Respiratory System- Resp
Abdominal Assessment- Abdo
Renal assessment- Renal
At the end of this section you can state:
The medical diagnosis for this patient is a pneumothorax or MI or whatever case study you have chosen.
It is most likely you will not reference in this section as this is the assessment of your
Number of references
I would expect you to use relevant references to support your nursing care. This will include the textbook, a pharmacology text, and some relevant research based articles. There is no set number, however please read around the topic. A reference for example on ?Pneumothorax in Rabbits? is NOT a suitable reference. However good use of relevant articles is required needed. You need to use GOOD references and use them appropriately.
This reference does not fit this sentence. What is being referenced here? You will see the marking criteria identify references used appropriately.
Please listen to the lecture provided to guide you in this assessment.