Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)
A.
Maslow’s hierarchy of needs
B.
A head-to-toe assessment
C.
Subjective data collection
D.
Review of systems
The Correct Answer and Explanation is:
In the context of a complete physical examination, the nurse uses various structured approaches to ensure thoroughness and accuracy in assessment. For a client presenting with intermittent chest pain upon exertion, the most relevant approaches are:
B. A head-to-toe assessment
D. Review of systems
Here’s why these approaches are appropriate:
Head-to-Toe Assessment
A head-to-toe assessment is a systematic method used by nurses to evaluate a patient’s overall health. This approach involves examining each body system, starting from the head and moving down to the toes. This method ensures that no aspect of the physical exam is overlooked. For a client with intermittent chest pain, a head-to-toe assessment helps the nurse to:
- Identify Symptoms: By evaluating the entire body, the nurse can identify any additional symptoms or physical signs that might be related to the chest pain.
- Detect Abnormalities: It allows the nurse to detect any abnormalities or issues in other systems that might be contributing to the chest pain or affecting overall health.
- Establish a Baseline: It provides a comprehensive baseline of the patient’s physical status, which is essential for monitoring changes over time or in response to treatment.
Review of Systems
The review of systems (ROS) is a method where the nurse asks the patient about symptoms they may be experiencing in different body systems. This approach is crucial for:
- Gathering Detailed Information: It helps gather detailed information about the client’s symptoms beyond what is immediately apparent from the chief complaint. For chest pain, the ROS might reveal related symptoms such as shortness of breath, palpitations, or gastrointestinal issues.
- Identifying Systemic Issues: It can help identify whether the chest pain is part of a broader systemic issue or related to specific organ systems, such as cardiovascular or gastrointestinal problems.
- Formulating a Plan: The information from the ROS helps in formulating a differential diagnosis and deciding on further diagnostic tests or interventions.
Why Not the Other Options?
- A. Maslow’s Hierarchy of Needs is more of a theoretical framework for understanding human motivation and needs rather than a direct method for conducting physical examinations. While it provides context for understanding patient priorities, it’s not a structured approach for physical assessment.
- C. Subjective Data Collection is important for gathering information about the patient’s experiences and feelings but does not constitute a comprehensive physical examination method. It’s part of the initial assessment but not a complete approach for physical examination.
In summary, using a head-to-toe assessment and a review of systems provides a thorough and organized approach to physical examination, especially important when assessing a client with intermittent chest pain.