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Please select one of the following case studies and complete the chart.
You are expected to role play the selected scenario with a family member to gather necessary data to complete the chart. For each person described in the following situations, discuss the developmental/age, socioeconomic, ethical considerations, and cross-cultural considerations that should be considered during the gathering of subjective and objective data, and the provision of health care. Discuss any additional information that might be needed before a judgment or diagnosis can be made.
- A. E. is a 35-year-old African American female, and is 5 months pregnant presenting to the office today for a routine prenatal visit. She complains that her neck feels swollen and that she has been feeling nervous and tired. She also complains about the heat, excessive sweating, and how she “can’t seem to get cool during these summer months.” She attributes all these complaints to her pregnancy.
- J. L. is a 55-year-old Caucasian female who had a CVA within the past week. J. L. is easily frustrated, anxious, fearful, and her speech is slurred. She needs verbal cuing for any task she is asked to carry out. She eats only food on the left side of the tray and responds only when approached from the left side.
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Components of assessment |
Subjective Diagnostic Reasoning (list key questions — use PQRSTU pneumonic) |
Objective Normal vs. abnormal findings (must note pertinent body systems to be examined) |
Differential diagnoses (list 3) Nurses diagnosis (list 1) |
List relevant labs and diagnostic studies (if any) |
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Normal |
Differential |
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Abnormal Findings |
Nurses Diagnosis |
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Developmental/age considerations:
Socioeconomic considerations:
Cross-cultural considerations:
Ethical considerations:
Additional info needed to formulate actual diagnosis:
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