Develop a plan of care for the lung and thorax system Demonstrate documentation of the lung and thorax assessment findings Explain how to conduct a physical assessment of the lung and thorax Assignment Overview In this writing assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints

QUESTION

Develop a plan of care for the lung and thorax system

Demonstrate documentation of the lung and thorax assessment findings

Explain how to conduct a physical assessment of the lung and thorax

Assignment Overview

In this writing assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client. You can access the grading rubric for this assignment here: Writing RubricPreview the document.

Deliverables

A three-page (750-word) paper

Step 1

Review the case scenario.

Kelsey Young is a seven-year-old African American girl who presents to the clinic today with her mother, Angie Young, as a follow-up to a visit to the emergency department after she had an episode of breathing difficulty the day before.

Onset: You ask Kelsey to describe what happened that brought her to the ER yesterday. She tells you she was at school and was coughing and couldn’t stop, and then her chest felt really tight and she felt like she couldn’t breathe right. She says that she got really scared, and the school nurse called an ambulance and her mom. You asked Kelsey if that ever happened before and she says no. You ask Mrs. Young if Kelsey has had any other respiratory or breathing problems. She tells you Kelsey always has a cough in the morning, but it seems to get better, and she never complains about it at school. She does get frequent colds, though. You ask Kelsey and Mrs. Young if she has noticed Kelsey has difficulty breathing or complains of chest pain. Kelsey tells you sometimes at recess she has trouble keeping up with the other kids because her chest hurts, and it is hard to breathe. Mrs. Young validates that she has noticed this as well.

Location: You ask Kelsey to show you where her breathing feels bad, and she points to her chest area.

Duration: You ask Mrs. Young to describe how long the coughing and shortness of breath has been occurring, and she tells you for about a year or so.

Characteristics: You ask Kelsey to describe what it feels like when she has trouble breathing or coughing. She tells you that her chest hurts and her breathing feels “funny,” not like normal. She tells you her coughing makes her chest feel funny too.

Aggravating factors: You ask Kelsey to tell you what makes her breathing feel worse. She tells you it gets worse when she runs around. She also tells you she coughs and sneezes a lot when she plays with her new kittens, Chico and Kiekie. She also tells you her chest sometimes hurts when “daddy smokes.”

Alleviating factors: You ask Kelsey what makes her breathing better and she tells you she’s not really sure, it just usually gets better.

Other background information: Kelsey is one of two children, and she has a younger brother, Marcus. Her father is an accountant and is a smoker. He has tried to quit but has been unsuccessful. Her mother is a stay-at-home mother and is very involved with her children. Kelsey loves to read, watch movies about animals, and play with her cats.

You perform the following assessment:

Lungs: Expiratory wheezes, otherwise clear

Thorax: Normal findings upon exam

Diagnosis and treatment: After ruling out other causes, Kelsey is diagnosed with asthma. She is placed on inhaled corticosteroids, an albuterol rescue inhaler, and Claritin for her allergies. Mrs. Young is advised to consider removing the kittens from the house and to have Mr. Young stop smoking in the house.

Step 2

Provide answers for each item below.

You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills. In your paper, discuss the following items:

Write a detailed explanation describing what you would say to the student, explaining the assessment conducted and the findings. Discuss the thorax assessment you performed and any additional assessments you would perform. What are other factors related to the probable diagnosis you would be concerned about with this client?

Explain how you would document your findings in the medical record.

Develop your plan of care. Identify one to two nursing diagnoses and one to two nursing interventions related to those diagnoses. The interventions need to be evidence based. Cite the references used in your plan in correct format.

Identify what client education (including creating an asthma action plan for the client) should be done for Kelsey, given her background and presenting illness. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention.

Step 3

Save and submit your assignment.

When you have completed your assignment, save a copy for yourself in an easily accessible place and submit a copy to your instructor using the dropbox.

References:

Giddens, J. F. (2010). The neighborhood: faculty navigation guide. Upper Saddle River, NJ: Pearson Education, Inc.

Mayo Clinic Staff. (2010, September 21). Childhood asthma. Retrieved from http://www.mayoclinic.com/health/childhood-asthma/DS00849

QUESTION

 Comprehensive Plan of Care and Assessment for a Pediatric Patient with Asthma

Introduction

Asthma is a chronic respiratory condition characterized by episodes of wheezing, coughing, and shortness of breath. In this essay, we will develop a plan of care for Kelsey Young, a seven-year-old girl diagnosed with asthma. We will discuss the assessment conducted, document the findings, identify nursing diagnoses and interventions, and outline client education strategies.

Assessment and Findings

During the assessment, Kelsey reported an episode of breathing difficulty, coughing, and chest tightness. She experiences these symptoms during physical activity, exposure to allergens, and when her father smokes. Physical examination revealed expiratory wheezes in her lungs, while her thorax appeared normal. Considering Kelsey’s symptoms and assessment findings, it is important to conduct further assessments, such as:
Pulmonary Function Test (Spirometry): This test evaluates lung function and measures airflow limitations, providing objective data for diagnosis and monitoring.
Allergy Testing: Identifying specific allergens triggering Kelsey’s symptoms can guide management strategies and avoidance measures.
Peak Expiratory Flow (PEF) Monitoring: Regular monitoring of peak flow rates can help assess the severity of asthma and monitor response to treatment.

Documenting Findings

Documentation is essential for effective communication among healthcare professionals. In the medical record, the findings should be accurately documented, including:
Presenting complaints, including frequency and duration of coughing, shortness of breath, and chest pain.
Assessment findings, such as the presence of expiratory wheezes and clear lung fields.
Relevant medical history, including family history of respiratory conditions and exposure to smoke and allergens.
Results of diagnostic tests, including spirometry, allergy testing, and PEF measurements.
Any additional findings or observations, such as triggers for symptoms or exacerbations.

Plan of Care

Nursing Diagnoses

Impaired Gas Exchange related to airway obstruction and reduced lung function.
Ineffective Breathing Pattern related to bronchospasm and inflammation.

Nursing Interventions

Provide education on proper inhaler technique and medication adherence, ensuring Kelsey and her parents understand the purpose, dosage, and side effects of prescribed medications.
Collaborate with Kelsey’s parents to identify triggers and develop an asthma action plan, including measures to avoid allergens, eliminate exposure to smoke, and create a smoke-free environment.
Teach Kelsey and her family about asthma triggers, symptoms, and early recognition of exacerbations. Provide instruction on the use of a peak flow meter to monitor lung function at home.
Encourage regular physical activity while ensuring appropriate management of symptoms before and during exercise. Emphasize the importance of maintaining optimal weight and overall health.
Establish regular follow-up visits to monitor asthma control, adjust medication as needed, and provide ongoing education and support.

Client Education and Evaluation

Given Kelsey’s background and diagnosis, client education is crucial. Teaching strategies include visual aids, demonstration, and interactive discussions to engage Kelsey and her parents. Key topics for client education include:
Asthma pathophysiology, triggers, and management strategies.
Proper use of inhalers, spacers, and peak flow meters.
Identifying and avoiding allergens, such as removing the kittens from the house and minimizing exposure to smoke.
Developing an asthma action plan, including recognizing symptoms, using rescue medication, and seeking medical assistance when necessary.
Evaluation of educational intervention can be done through knowledge assessments, return demonstrations of inhaler techniques, and regular communication with Kelsey and her parents to assess symptom control and adherence to the asthma action plan.

Conclusion

A comprehensive plan of care for Kelsey’s asthma involves a thorough assessment, accurate documentation, and evidence-based interventions. By addressing Kelsey’s unique needs and providing education to promote self-management, we can empower her and her family to effectively manage her asthma, minimize symptoms, and improve overall lung health. Regular follow-up and ongoing support will be essential to monitor her progress and make adjustments to the plan of care as needed.