Clinical Evaluations
From the patient analysis, I came up with both pertinent positive and negative findings. The positive findings include the presence of shortness of breath, the production of a wheezing sound, the fact that she has been hospitalized for asthma four times, and the presence of disease in her family history from both the mum and the dad. The negative findings include the no recorded history of drug use; she is unsure of her grandparent’s disease history. I would like to know the relationship she shares with her parents, given that she is the only child and seems not to have a good relationship with the grandparents. I would also like to know how her performance at school is like and how often she does exercise (Berliner et al., 2016). Based on my findings, the girl could have either asthma, acute respiratory distress, or congestive heart failure disease.
All of the diseases make the victims suffer from shortness of breath. It is likely to be asthma because she already has a history of it (Abuel-Reesh, 2017). It is likely to be acute distress as she has a wheezing sound as she breathes. Congestive heart failure is characterized by both shortness of breath and wheezing sound. To perform priority diagnosis, I will be guided by Abrahams Maslow’s hierarchy of needs for prioritization. Beginning with the basic physiological needs, which include relation an airway for an adequate supply of air, enough rest for maximum sleep and a healthy diet. It is followed by ensuring safety and security that the creation of a free environment, hygiene, and patient education concerning shortness of breath (Perez Rivaz et al., 2016). The next step is love and belonging, where I will create an environment for her to feel secure and accepted to avoid isolation. Through this, I will achieve my next step that is raising the patient’s self-esteem. Lastly is to empower the society to treat all patients in a good manner and to be supportive.
References
Abuel-Reesh, J. (2017). A knowledge-based system for diagnosing shortness of breath in infants and children.
Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The differential diagnosis of dyspnea. Deutsches Ärzteblatt International, 113(49), 834.
Pérez Rivas, F. J., Martín‐Iglesias, S., Pacheco del Cerro, J. L., Minguet Arenas, C., Garcia Lopez, M., & Beamud Lagos, M. (2016). Effectiveness of nursing process use in primary care. International journal of nursing knowledge, 27(1), 43-48.