Discussion Topics, Chapter 47, Data Collection in Client Care

Discussion Topics Learning Objective(s)

1. A 35-year-old woman injured in a motor vehicle accident is 1, 5

brought to the healthcare facility. The client is confused and has

periods of lethargy and irritability. She also exhibits difficulty

breathing. The client’s clothes are disheveled and have a strong

odor. After stabilizing the client, the healthcare provider orders a

UTox test be done on the client and asks the nurse to continue to

monitor the client closely.

a. What might be the rationale for a UTox test in this

situation? UTox is to evaluate what is in the blood or

the urine to determine driving under the influence and

if, what drug and the amount that was abused.

b. What areas should the nurse closely monitor? You would

monitor the total body because this would be

considered an total body situation and will monitor all

organs at once; this will help with noticing if there’s

any issues as of mental disorders.

2. A 12-year-old boy in an emaciated condition is admitted to the 1, 2, 8

healthcare facility. Assessment reveals severe blisters on his feet

and an open wound on his left ankle. The boy also complains of

giddiness, weakness, and body ache. When asked about his

family and home, he states that he has run away from a juvenile
detention home where he had been placed for drug abuse.

a. What objective and subjective data should the nurse

obtain from this client and why? Documentation: Name,

medical record number, age, date, time, probable

medical diagnosis, chief complaint, the source of

information (two patient identifiers). Past medical

history: Prior hospitalizations and major illnesses and

surgeries. Assess pain: Location, severity, and use of a

pain scale. Allergies: Medications, foods, and

environmental; nature of the reaction and seriousness;

intolerances to medications; apply allergy band and

confirm all prepopulated allergies in the electronic

medical record (EMR) with the patient or caregiver.

Psychosocial: Evaluate need for a sitter or video

monitoring, any signs of agitation, restlessness,

hallucinations, depression, suicidal ideations, or

substance abuse. Vital signs: Temperature recorded in

Celsius, heart rate, respiratory rate, blood pressure,

pain level on admission, oxygen saturation.

Nutritional: Appetite, changes in body weight, need for

nutritional consultation based on body mass index

(BMI) calculated from measured height and weight on

admission.
b. What other data should the nurse record and report?

Cardiovascular: Heart sounds; pulse irregular,

regular, weak, thready, bounding, absent; extremity

coolness; capillary refill delayed or brisk; presence of

swelling, edema, or cyanosis. Respiratory: Breath

sounds, breathing pattern, cough, character of

sputum, shallow or labored respirations, agonal

breathing, gasps, retractions present, shallow,

asymmetrical chest rise, dyspnea on exertion.

Gastrointestinal: Bowel sounds, abdominal tenderness,

any masses, scars, character of bowel movements,

color, consistency, appetite poor or good, weight loss,

weight gain, nausea, vomiting, abdominal pain,

presence of feeding tube. Neuromuscular: Level of

consciousness using AVPU (alert, voice, pain,

unresponsive); Glasgow coma scale (GCS); speech

clear, slurred, or difficult; pupil reactivity and

appearance; extremity movement equal or unequal;

steady gait; trouble swallowing. Integument: Turgor,

integrity, color, and temperature, Braden Risk

Assessment, diaphoresis, cold, warm, flushed, mottled,

jaundiced, cyanotic, pale, ruddy, any signs of skin

breakdown, chronic wounds.

3a. A 40-year-old woman visits a healthcare facility for an 6, 11, 12

ultrasound.

a. What is ultrasound imaging? Ultrasound imaging

(sonography) uses high-frequency sound waves and

are produced by a transducer, which creates “echoes”,

to view inside the body and nearly every structure

also. Because ultrasound images are captured in real-

time, they can also show movement of the body's

internal organs as well as blood flowing through the

blood vessels.

b. What are some common reasons for ultrasound imaging?

Ultrasound is used for many reasons, including to:

● View the uterus and ovaries during pregnancy

and monitor the developing baby's health

● Diagnose gallbladder disease, tumors in many

areas of the body

● Evaluate blood flow

● Guide a needle for biopsy or tumor treatment

● Examine a breast lump

● Check your thyroid gland

● Detect genital and prostate problems

● Assess joint inflammation (synovitis)

 ● Evaluate metabolic bone disease

c. What are some nursing considerations related to the

examination? For some scans, such as a gallbladder

ultrasound, your doctor may ask that you not eat or

drink for up to six hours before the exam. Others, such

as a pelvic ultrasound, may require a full bladder. You

may need to drink up to six glasses of water two hours

before the exam and not urinate until the exam is

completed. Wear loose clothing to your ultrasound

appointment. You may be asked to remove jewelry

during your ultrasound, so it's a good idea to leave any

valuables at home. Ultrasound is usually painless.

However, you may experience mild discomfort as the

sonographer guides the transducer over your body,

especially if you're required to have a full bladder, or

inserts it into your body. A typical ultrasound exam

takes from 30 minutes to an hour. When your exam is

complete, a doctor trained to interpret imaging studies

(radiologist) analyzes the images and sends a report to

your doctor. Your doctor will share the results with

you. You should be able to return to normal activities

immediately after an ultrasound.