Show The complete subjective health assessment is commonly referred to as a . It provides an overview of the client’s current and past health and illness state. You conduct it by interviewing the client as illustrated in Figure 1.1, asking them questions, and listening to their narrative. Figure 1.1: Nurse interviewing the clientThis information is often shared verbally with you or in the way that the client can best communicate. It is also sometimes collected through a standardized form that the client completes. In some cases, it also includes information shared by a family member, friend, or another health professional when the client is unable to communicate.
Clients are sometimes accompanied by . Care partners are family and friends who are involved in helping to care for the client. You may hear care partners being referred to as “informal caregivers” or “family caregivers,” but “care partner” is a more inclusive term that acknowledges the energy, work, and importance of their role. The complete subjective health assessment is part of assessment, the first component of the nursing process (assessment, analysis/diagnosis, planning, implementation and evaluation) outlined in Figure 1.2. Figure 1.2: The nursing processAs illustrated in Figure 1.2, the assessment phase of the nursing process involves collecting (information that the client shares) and (information that you collect when performing a physical exam). See Table 1.1 for an overview and examples of subjective and objective data. This book focuses on subjective data collection in the context of the complete subjective health assessment.
Table 1.1: Overview and examples of subjective and objective data As the word “subjective” suggests, this type of data refers to information that is spontaneously shared with you by the client or is in response to questions that you ask the client. Subjective data can include information about both symptoms and signs. In the context of subjective data, are something that the client feels, as illustrated in Figure 1.3 (e.g., nausea, pain, fatigue). You won’t know about a symptom unless the client tells you. are something that the health professional can observe, such as a rash, bruising, or skin perspiration, also illustrated in Figure 1.3. Although you can observe signs, in the context of a subjective assessment, the client shares this subjective information with you. For example, a rash is both subjective and objective data as it could be something that the client shares with you, but it is also something that you can observe. On the other hand, if the client says that the rash is itchy, that would be considered subjective data and, in this case, it would be a symptom because it is something the client feels and you can’t observe. Figure 1.3: Symptom versus sign A term often used in reference to, or in place of, the complete subjective health assessment. Care partners are family and friends who are involved in helping to care for the client Information that the client shares with the health professional. Information that the health professional collects when performing a physical exam. Something that the client feels. Something that the health professional observes.
Kaye went on a picnic with her friends at the beach. Everyone brought food and shared them for lunch. Moments after biting off a chunk of sandwich, Kaye went dizzy and complained of severe shortness of breath. IT turned out that the sandwich is a peanut butter and jelly ensemble, and Kaye is allergic to peanuts. She was immediately rushed to the emergency department and was diagnosed with anaphylactic shock. What is Anaphylactic Shock?Anaphylactic shock occurs rapidly and is life-threatening.
PathophysiologyAnaphylaxis occurs in an individual after reexposure to an antigen to which that person has produced a specific IgE antibody.
Statistics and IncidencesAnaphylaxis occurs worldwide and in different ages.
CausesAllergy symptoms aren’t usually life-threatening, but a severe allergic reaction can lead to anaphylaxis.
Clinical ManifestationsAn anaphylactic reaction produces the following symptoms:
PreventionBecause anaphylactic shock occurs in patients already exposed to an antigen and who have developed antibodies to it, it can often be prevented.
ComplicationsThe complications of anaphylactic shock include:
Assessment and Diagnostic FindingsBecause anaphylaxis is primarily a clinical diagnosis, laboratory studies are not usually required and are rarely helpful.
Medical ManagementTreatment of anaphylactic shock include:
Pharmacologic TherapyMedications used for a patient at risk or under anaphylactic shock are:
Nursing ManagementThe nurse has an important role in preventing anaphylactic shock. Nursing AssessmentCommunication is an essential part of assessment.
Nursing DiagnosisBased on the assessment data, the nursing diagnoses appropriate for the patient are:
Nursing Care Planning and GoalsMain Article: 4 Anaphylactic Shock Nursing Care Plans The major goals for a patient with anaphylactic shock are:
Nursing InterventionsNursing interventions for the patient are:
EvaluationExpected patient outcomes include:
Discharge and Home Care GuidelinesUpon discharge, the patient and family need to learn about the following:
Documentation GuidelinesThe focus of documentation include:
Practice Quiz: Anaphylactic ShockHere are some practice questions for this study guide. Please visit our nursing test bank page for more NCLEX practice questions. 1. Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform? A. Removing the stinger by scraping it. B. Applying a cold compress. C. Taking an oral antihistamine. D. Calling the 911. 1. Answer: A. Removing the stinger by scraping it.
2. Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a drug should include which of the following actions first? A. Administering oxygen B. Inserting an I.V. catheter C. Obtaining a complete blood count (CBC) D. Taking vital signs 2. Answer: A. Administering oxygen
3. Following the initial care of a client with asthma and impending anaphylaxis from hypersensitivity to a drug, the nurse should take which of the following steps next? A. Administer beta-adrenergic blockers. B. Administer bronchodilators. C. Obtain serum electrolyte levels. D. Have the client lie flat in the bed. 3. Answer: B. Administer bronchodilators.
4. Anaphylactic shock is associated with which type of hypersensitivity? A. Type I hypersensitivity. B. Type II hypersensitivity. C. Type III sensitivity. D. Type IV sensitivity. 4. Answer: A. Type I hypersensitivity. 5. What are some conditions that may precipitate anaphylactic shock? A. Insects. B. Food. C. Medicines. D. All of the above. 5. Answer: D. All of the above.
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