Describe the assessment you need to perform at this time
What will be an ideal response?
• Begin with recording her medical diagnoses, medication profile, and allergies. Has she participated
in any advance planning? Does she have any legal care documents?
• Do a brief systems or functional health patterns review to detect important signs and symptoms.
Assess for discomfort, pain, nausea, and dyspnea so that prompt interventions can be
implemented.
• Perform a functional assessment of activities of daily living to evaluate her abilities, food and fluid
intake, and patterns of sleep and rest.
• Assess her ability to cope with the diagnosis and prognosis of the illness as well as the ability of
her family or other support systems to provide needed care. Does she have any significant social or
spiritual concerns? How is she responding to the stress of a terminal illness?
• The physical assessment may be abbreviated, focusing on reported symptoms and specific to her
underlying disease process.
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