Need help please - I'm so new at this

hi, cute1 and welcome to allnurses.

it sounds like you are being expected to get an assessment and determine the patient's problems based upon the scenario you were given. since you are new to allnurses, i want to point out that on this particular forum there is a thread that has been highlighted with a sticky so it always appears in the very first listings of the threads of this forum. it is titled health assessment resources, techniques, and forms and this link will put you directly into it: https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html. you will find many links there to web pages that will help you with assessing patients.

when you do these case studies where the patient doesn't exist, the patient data has been given to you. you must read the scenario and list out what is abnormal.

data you need to obtain: i don't know how in depth your instructor wants you to assess the patient. does he want a head to toe assessment? a body systems assessment? or, just an assessment of this patient's respiratory system since he has a respiratory disease (copd) and a respiratory related symptom (cough)? to cut things short for this reply i would assess the respiratory system, for sure. here is a link to the respiratory assessment page on one of my favorite assessment sites and i'll let you read it and extract the information you need to assess off of it:

http://medicine.ucsd.edu/clinicalmed/lung.htm - the lung exam

also, don't forget to assess your patient's ability to perform his activities of daily living (adls). his respiratory status is going to affect his ability to move around, sleep, medications may affect his appetite, and his breathing may affect his ability to speak, dress and feed himself.

equipment you would use to assist in your data collection include the tools of the physical examination. there are four examination techniques that we use:

1. inspection - what you observe. so, your primary piece of "equipment" would be your eyes. sometimes you'll use an otoscope or an ophthalmoscope. you might use eye charts, a flashlight or penlight, rulers or tape measures, and a reflex hammer
   
2. palpation - what you feel. so, your primary piece of "equipment" would be your fingers and hands.
   
3. percussion - vibrations that you hear. so, your primary piece of "equipment" would be your ears and hands.
   
4. auscultation - listing. the primary piece of "equipment" used is the stethoscope.

i would look up the signs and symptoms of copd. copd is a very broad diagnosis. it actually can be further broken down into one of four respiratory diseases:

1. chronic obstructive asthma
   
2. chronic obstructive bronchitis
   
3. emphysema
   
4. chronic bronchitis with emphysema

each has a slightly different etiology and pathophysiology although some of the physical symptoms may be the same. the difference in the etiology and pathophysiology may be enough to make a difference in the nursing diagnosis you choose.

when you are doing these case scenarios that are not real patients, your instructors sometimes want you to pull in the signs and symptoms of these diseases and use them as your abnormal assessment data to support some nursing diagnoses. you'd have to ask your instructor if that is what they want. since this is due tomorrow it might be too late to do that.

psychosocial aspects/needs would indicate that your instructor intended for you to look at this in the patient. did you miss a lecture on assessing a patient? because psychosocial needs is almost always addressed in assessing the patient lectures in nursing school. if you have a copy of taber's cyclopedic medical dictionary you will find a nursing assessment in the center of the book under the listing of "nursing assessment tool". it has a section of "social interactions". it includes things like marital status, support persons, the patient's role in the family, problems they are experiencing related to their illness or condition (your patient has a big one: doesn't have enough money to pay for his prescription medication), and any changes in speech. basically, how does the patient interact within their environment, community and with other people. this is how you assess psychosocial.

problems are based directly upon anything that is abnormal. doing any assessment assumes that you know what the normal assessment should be. anything that deviates from "normal" is "abnormal" and, therefore, a problem. in the world of care planning, "abnormal" data are called "symptoms" and nanda (north american nursing diagnosis association) calls them defining characteristics. these defining characteristics are the backbone of the nursing diagnoses. your priority (main) needs /problems for this client are going to be the abnormal data you get during your assessment. you were already give two in the scenario:

1. he didn't have enough money to fill his prescription medications - he needs to get his medications
   
2. coughing - he may need help to clear his airway of secretions, he may be fatigued from the coughing

if you look up and use the symptoms of copd you'll have more.

here are two websites that have links to student case studies of real patients that their instructor posted on the internet for others to look at. it will give you an idea of how a case study is constructed, at least for this particular instructor. can't say what your instructor wants from you. only you can know that. your teacher should have given you some kind of guideline on how to present this paper. you should follow your teacher's directions.

• http://learn.sdstate.edu/craigg/ercases.html
  
• http://learn.sdstate.edu/craigg/ersp01.html

Oh, I imagine your lectures and books had a lot more to do with your understanding of this than you think. I just restated some of it in a little bit of a different way that helped it click into place. Please review your class notes and books again and see if you don't get a better understanding a second time around, OK? And, check out some of those assessment links and the thread I posted for you. Some of them have really excellent information on them. Assessment comes up a lot on the student forums. It's hard to find an assessment form you can download and copy. Most of the time you are left to make up your own. I have been working on one over the summer and it isn't completed yet. And I know it will not meet the needs of every student either. I had my own little one page assessment guideline that I added to and carried around on my clipboard at work for years and used as a reference for charting as well. That's just how it is in this business.