NU581 H2T Case Study

Student Name

Purdue University Globle 

NU580 FNP II – Primary Care of Children and Adolescents’ Health

Prof. Name

Date

NU581 H2T Case Study

A focused nursing assessment for Ms. Rose requires a comprehensive, patient-centered approach that combines therapeutic communication, systematic physical examination, interdisciplinary collaboration, preventive healthcare, and individualized discharge planning. By assessing skin integrity, cardiovascular and neurological status, thyroid and breast health, abdominal findings, and home safety needs, nurses can identify potential complications early, develop appropriate interventions, and improve patient outcomes through evidence-based care.

Introduction

A focused health assessment is a critical nursing responsibility that helps identify immediate patient concerns while supporting long-term health promotion. For Ms. Rose, the assessment should address her presenting symptoms, medical history, physical findings, and psychosocial needs. Using standardized assessment techniques, clear documentation, and effective communication allows healthcare providers to deliver safe, holistic, and coordinated care.

Therapeutic Communication During a Focused Interview

Therapeutic communication establishes trust, encourages patient participation, and promotes accurate data collection. During the interview, nurses should demonstrate empathy, active listening, and cultural sensitivity while respecting the patient’s preferences and privacy.

Recommended Interview Question

An effective open-ended question is:

“Tell me, Ms. Rose, what are your concerns and preferences regarding this interview?”

This question:

• Encourages patient autonomy.

• Builds rapport and trust.

• Identifies cultural, emotional, and personal considerations.

• Supports individualized care planning.

Major Functions of the Skin

The skin is the body’s largest organ and performs several essential physiological functions that protect overall health.

Primary Functions of the Skin

• Serves as a protective barrier against microorganisms and injury.

• Prevents excessive fluid and electrolyte loss.

• Protects underlying tissues from ultraviolet (UV) radiation.

• Provides sensory perception for touch, pain, pressure, and temperature.

• Regulates body temperature through perspiration and blood vessel dilation.

• Supports vitamin D synthesis, which is necessary for healthy bone metabolism.

Documentation of Ms. Rose’s Foot Assessment

Accurate documentation promotes continuity of care and supports timely clinical decision-making.

Assessment Findings

Ms. Rose’s right lower leg demonstrates:

• An erythematous ulcer.

• Peripheral skin discoloration surrounding the wound.

• A cool extremity on palpation.

• A palpable dorsalis pedis pulse.

• Heart rate of 76 beats per minute.

These findings may suggest impaired peripheral circulation or vascular insufficiency. Continued vascular assessment and close monitoring are recommended to prevent disease progression.

Interdisciplinary Team Members Involved in Ms. Rose’s Care

Patients with multiple chronic conditions benefit from collaborative care involving various healthcare professionals.

Members of the Healthcare Team

Internist

Coordinates overall medical management and monitors chronic health conditions.

Cardiologist

Evaluates hypertension, cardiovascular disease, and peripheral vascular disorders.

Endocrinologist

Manages diabetes mellitus and optimizes blood glucose control.

Dermatologist

Evaluates and treats skin disorders, including venous ulcers.

Plastic and Reconstructive Surgeon

Provides advanced wound reconstruction when extensive tissue damage is present.

Vascular Surgeon

Assesses and treats arterial or venous insufficiency affecting lower extremity circulation.

Registered Nurses and Counselors

Provide patient education, wound care, emotional support, medication teaching, and care coordination.

Thyroid Assessment: Anatomical Landmarks and Examination Technique

Assessment of the thyroid gland includes identifying important anatomical landmarks and evaluating gland size, symmetry, and mobility during swallowing.

Anatomical Landmarks

The examiner should identify:

• Thyroid cartilage

• Cricoid cartilage

• Cricothyroid membrane

• Trachea

• Thyroid gland

• Thyroid isthmus

Thyroid Examination Procedure

The examiner generally stands behind the patient and performs the assessment using the following sequence:

• Palpate downward from the chin.

• Identify the thyroid cartilage.

• Locate the cricoid cartilage.

• Identify the cricothyroid membrane.

• Palpate the tracheal rings.

• Recognize that the thyroid isthmus lies over the first two tracheal rings.

• Ask the patient to slightly flex the neck.

• Instruct the patient to swallow while palpating each thyroid lobe.

• Evaluate gland symmetry, enlargement, tenderness, and the presence of nodules.

Breast and Axillary Assessment

Routine breast examinations contribute to early detection of breast disease and support preventive healthcare.

Anatomical Landmarks

Assessment includes evaluation of:

• Four breast quadrants

• Nipple-areola complex

• Axillary tail of Spence

Inspection

Observe for:

• Differences in breast size or symmetry.

• Skin discoloration.

• Dimpling or retraction.

• Nipple inversion.

• Spontaneous nipple discharge.

Palpation

When a breast mass is detected, evaluate:

• Shape

• Consistency

• Mobility

• Tenderness

• Changes in size over time

Hard, irregular, and fixed masses require prompt diagnostic evaluation because they are more suspicious for malignancy.

Axillary Examination

Palpate axillary lymph nodes for:

• Enlargement

• Tenderness

• Firmness

• Mobility

Abnormal lymph node findings may indicate infection, inflammation, or metastatic disease.

Important History Questions During a Breast Examination

Obtaining an accurate health history helps guide clinical assessment and identify patients requiring additional evaluation.

Recommended Questions

Are you currently menstruating?

Breast examinations are generally more comfortable and accurate shortly after menstruation because breast tissue is less tender.

Have you noticed breast lumps, pain, or nipple discharge?

These symptoms may indicate benign or malignant breast conditions that require further assessment.

Current Mammography Screening Recommendations

Breast cancer screening recommendations vary according to patient age and individual risk factors.

American Cancer Society Recommendations

• Ages 40–44: Women may choose to begin annual mammography.

• Ages 45–54: Annual mammography is recommended.

• Age 55 and older: Women may continue annual screening or transition to mammograms every two years.

Patients with a significant family history or increased genetic risk may require earlier and more frequent screening.

Individualizing the Nursing Assessment

Nursing assessments should always be tailored to the patient’s presenting condition while prioritizing life-threatening problems.

Priority Assessment Areas

• Airway

• Breathing

• Circulation

• Vital signs

• Oxygen saturation

• General appearance

Concerning Subjective Findings

Immediate evaluation is warranted if Ms. Rose reports:

• Shortness of breath

• Difficulty breathing

• Frequent gasping for air

• Chest pain

• Increasing fatigue

• Cyanosis

These symptoms may indicate respiratory or cardiovascular compromise requiring urgent intervention.

Disease Prevention and Health Promotion Strategies

Preventive care improves quality of life and reduces complications associated with chronic illness.

Recommended Interventions

• Smoking cessation counseling.

• Diabetes self-management education.

• Medication adherence.

• Routine physical activity as tolerated.

• Participation in recreational and social activities to improve emotional well-being.

• Regular follow-up with healthcare providers.

Clinical Significance of the S3 Heart Sound

The third heart sound (S3), commonly called a ventricular gallop, occurs during rapid ventricular filling in early diastole.

Clinical Importance

In older adults, an S3 heart sound may indicate:

• Systolic heart failure.

• Left ventricular dilation.

• Increased ventricular filling pressures.

Although an S3 may be a normal finding in younger adults and pregnancy, its presence in older patients warrants additional cardiovascular evaluation.

Ms. Rose’s Glasgow Coma Scale (GCS)

Based on the assessment findings, Ms. Rose demonstrates:

• Opens eyes to verbal stimuli.

• Speaks with comprehensible but slurred speech.

• Is alert to her name but not place.

• Obeys verbal commands.

• Appears fearful and agitated.

Glasgow Coma Scale Score

A GCS score of 12 indicates moderate impairment of consciousness and requires ongoing neurological assessment.

Auscultation of Bowel Sounds and Abdominal Palpation

The abdominal examination follows a standardized sequence to prevent alteration of bowel sounds.

Correct Examination Sequence

1. Inspection

2. Auscultation

3. Percussion

4. Palpation

Auscultation

The examiner should:

• Listen to bowel sounds before palpation.

• Assess sound frequency and character.

• Auscultate for vascular bruits over the abdominal aorta and renal arteries.

Normal bowel sounds typically occur 2–5 times per minute.

Abnormal findings include:

• Absent bowel sounds: May indicate paralytic ileus.

• Hyperactive bowel sounds (borborygmi): May suggest bowel obstruction.

• Abdominal bruit: May indicate vascular disease, including abdominal aortic aneurysm or renal artery stenosis.

Palpation

Palpation should proceed from light to deep and begin away from painful areas.

Assess for:

• Tenderness

• Guarding

• Rigidity

• Organ enlargement

• Palpable masses

Home Safety Precautions for Discharge Teaching

Effective discharge planning promotes patient independence while reducing preventable complications and hospital readmissions.

Home Safety Recommendations

• Maintain adequate lighting throughout the home to reduce fall risk.

• Keep hot objects and electrical devices away from affected areas.

• Use assistive devices or side rails when indicated.

• Educate caregivers regarding medication administration and adherence.

• Reinforce proper wound care techniques.

• Provide emergency contact information.

• Schedule follow-up appointments before discharge.

Conclusion

A comprehensive nursing assessment for Ms. Rose requires more than completing a physical examination. It involves therapeutic communication, accurate documentation, systematic assessment techniques, interdisciplinary collaboration, preventive health education, and individualized discharge planning. By integrating evidence-based assessment practices with patient-centered care, nurses can identify health risks early, improve clinical outcomes, and support long-term wellness.

References

American Cancer Society. (2025). American Cancer Society recommendations for the early detection of breast cancer. https://www.cancer.org/cancer/screening/breast-cancer-screening-guidelines.html

Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer.

Hinkle, J. L., & Cheever, K. H. (2025). Brunner & Suddarth’s textbook of medical-surgical nursing (16th ed.). Wolters Kluwer.

Jarvis, C. (2024). Physical examination and health assessment (9th ed.). Elsevier.

National Institute of Diabetes and Digestive and Kidney Diseases. (2025). Your skin. https://www.niddk.nih.gov/health-information

National Library of Medicine. (2025). Glasgow Coma Scale. https://www.ncbi.nlm.nih.gov/books/

NU581 H2T Case Study

StatPearls Publishing. (2025). Abdominal examination. https://www.ncbi.nlm.nih.gov/books/

World Health Organization. (2025). Health promotion. https://www.who.int/health-topics/health-promotion