1. Develop at least 2 complete nursing diagnoses related to client’s history.
Rape-Trauma Syndrome related to forced sexual penetration as evidenced by shame, fear, and helplessness. (610)
Risk for Post Trauma Syndrome related to inadequate social support. (594)
Stress Overload related to chronic illness as evidenced by reports of difficulty in functioning. (768)
Risk for ineffective activity planning related to insufficient support systems. (49)
2. Identify the components included in a client’s health history.
Biographic Data-The client’s demographic data, should include the name, address, age, sex, marital status, occupation, religion, health care financing, and their primary care provider.
Chief Complaint-The reason for the visit should be obtained and documented in the client’s own words.
History of Present Illness-Find out when the symptoms started and how did they occur such as suddenly or gradually. Determine the intensity of the pain. Have the client to describe the quality of symptoms, such as sputum, vomit, or discharge; by asking the color and quality such as watery, thick, or bloody. Determine …show more content…
Low pitched sound (lub) that occur when the atrioventricular valve closes. It is longer than the S2 sound and has less intensity than the S2 sound in the aortic and pulmonic. However, it is louder than or equal to the S2 sound in the tricuspid and mitral. The S2 (dub) sound occurs as the semilunar valves close and has a higher pitch than the S1 sound, this sound is louder in the aortic and pulmonic, but has less intensity or is equal to the S1 sound in the tricuspid and mitral. The S3 sound (lub-dub-ee) occurs right after the S2 sound and often disappears if the client sits up. This sound is normal for children and young adults. However, it may indicate heart failure in older adults. The S4 (dee-lub-dub) happens near the end of diastole, but before the S1 and may be heard in older clients and could be an indication of hypertension.
Rape-Trauma Syndrome related to forced sexual penetration as evidenced by shame, fear, and helplessness. (610)
Risk for Post Trauma Syndrome related to inadequate social support. (594)
Stress Overload related to chronic illness as evidenced by reports of difficulty in functioning. (768)
Risk for ineffective activity planning related to insufficient support systems. (49)
2. Identify the components included in a client’s health history.
Biographic Data-The client’s demographic data, should include the name, address, age, sex, marital status, occupation, religion, health care financing, and their primary care provider.
Chief Complaint-The reason for the visit should be obtained and documented in the client’s own words.
History of Present Illness-Find out when the symptoms started and how did they occur such as suddenly or gradually. Determine the intensity of the pain. Have the client to describe the quality of symptoms, such as sputum, vomit, or discharge; by asking the color and quality such as watery, thick, or bloody. Determine …show more content…
Low pitched sound (lub) that occur when the atrioventricular valve closes. It is longer than the S2 sound and has less intensity than the S2 sound in the aortic and pulmonic. However, it is louder than or equal to the S2 sound in the tricuspid and mitral. The S2 (dub) sound occurs as the semilunar valves close and has a higher pitch than the S1 sound, this sound is louder in the aortic and pulmonic, but has less intensity or is equal to the S1 sound in the tricuspid and mitral. The S3 sound (lub-dub-ee) occurs right after the S2 sound and often disappears if the client sits up. This sound is normal for children and young adults. However, it may indicate heart failure in older adults. The S4 (dee-lub-dub) happens near the end of diastole, but before the S1 and may be heard in older clients and could be an indication of hypertension.