Assessment 2 Essay: Case study Identify Annie’s Health history data (using Gordon’s functional patterns as a framework) and her physical assessment data. Discuss your plan of care based on the data identified. • Forty four year old Annie has presented to ED complaining of excruciating, increasing pain in her right big toe for the last two days. She says it hurts so much she’s had to sleep with her foot on a pillow with no sheets covering it and consequently she has not slept for the last two days. On examination, her toe appears red and swollen. It is warm to touch and Annie flinches when you do. On palpation, a throbbing pulsation can be felt. Annie also says she cannot weight-bear on this foot and hence she has to hop to get around. Her vital signs are: T38, P100, R20 and BP 140/90. Her LFT shows no abnormalities but her SE shows raised uric acid levels. Her provisional medical diagnosis is “Gout”. The MO prescribes oral Allopurinol, 600mg daily and Ibuprofen, 200-400mg, 4/24. He also de cides to admit her for observation and further investigation. • Annie has a female partner (wife) who is away working in the mines and Annie is concerned about who will mind their 3yr old son as both sets of grandparents are unavailable. NRSG125 Guide for Assessment 2 essay Preparation beforehand Construct a concept map based on the information you collected. Identify the issues in order of priority and write in paragraph style about each identified issue, using the template on how to write academic paragraphs as provided in your ACU study guide. One: Identify the person Understand the background of the person Understand all the details provided about the person Clarify all the symptoms, identified problems and diagnoses so you understand who you are dealing with and what problems they may have Two: Understand the pathophysiology of the diagnoses and the pharmacological principles of the medications the person is on Review the normal physiology of the body systems involved in the various diagnoses. Review the pathophysiology related to the diagnoses so you understand the variation from normal Identify the purpose of the medications in relation to the diagnoses Understand the effect of the medication on the pathophysiology of the diagnoses Three: Assessment Identify all the domains of health to be assessed remember to use Gordon’s health assessment framework (see attached document) : physical, psychological, social, cultural, spiritual, intellectual and other domains you may identify Identify the information required to plan care for this client’s specific problems Four: Essay writing Now begin your essay: Make sure you use Gordon’s framework to set out the body of your test and to: Discuss the focus of care and give the reason why you have chosen such a focus based on the data identified.
