NUR250 Assessment 1S2 2017 Assignment template NUR250 Assessment 1 S2 2017 Assignment template It is recommended you do not delete the heading and the information below. Please note: As indicated in Assessment 1 information, a cover sheet, title and contents pages are not required Before you begin take a minute to fill in your details in the footer to ensure your document is identifiable. To access the footer, double click on the grey writing “Last name….” at the bottom of the page above. Once you have done that, double click here to come back to this page. Information about the required line spacing and font size and type is in the Assessment 1 information document in the Assessment 1 folder on NUR250 Learnline. Take a minute to check that this document meets those requirements. To avoid or minimise problems with formatting, it is recommended you
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Start to write your assignment here. Word count is calculated from this point. Task 1: Patient assessment Respiratory Assessment
An initial assessment for Rosie involves a respiratory assessment. This assessment involves reviewing Rosie’s respiratory patterns (Clinical Guidelines, 2017). The patterns assessed include the respiratory rate of the patient and her blood oxygen saturation levels. Based on the admission assessment, a review of Rosie’s respiratory patterns, she recorded low blood oxygen saturation levels (SpO2) of 90%. This SpO2 level recorded by the patient lies below the recommended SpO2 levels of a healthy person. From the results, Rosie possibly has a respiratory illness that may be the reason for the health problems she currently faces. While Rosie’s respiratory rate is 20 breaths a minute, which is still relatively high, the SpO2 levels indicate that she may have a respiratory condition. In case the assessment is skipped, Rosie is exposed to worsening respiratory conditions. As such, disregarding the respiratory assessment may worsen Rosie’s condition, making it more difficult to stabilize her health. Cardiovascular Assessment This assessment involves reviewing the patient’s circulatory system, which is the system responsible for blood circulation within the body (Clinical Guidelines, 2017). As blood is transported within the body; it carries nutrients and other components to the rest of the body. As such, based on the vital signs during the admission assessment, Rosie should undergo a cardiovascular assessment during care. From her health history, Rosie has had hypertension, and from the admission assessment, she recorded 150 over 95, which relatively high. Moreover, Rosie’s heartbeat rate of 110 beats per minute is relatively high (“What is a Normal Heart Rate?” 2015). Since the cardiovascular system of the body is very essential, and Rosie’s has recorded unhealthy levels, evading the cardiovascular assessment will put Rosie’s health at risk. Avoiding the assessment translates to an incomplete assessment of the patient since the patient has shown vital cardiovascular problems. Optical Assessment Some of Rosie’s recent admissions have been as a result of a fall. During her admission, haematomas were observed on Rosie’s eyes. These signs predict an eye problem. Further, as she ages, her eyesight deteriorates. Moreover, the superficial laceration on Rosie’s left eye may make her eyes faulty. Rosie probably has an eye problem. Thus, it is important to conduct an optical assessment on her, to provide quality care for her eyes. This move will assist to reduce the accidents that Rosie would have otherwise faced if she had no optical assessment during her admission. References Clinical Guidelines (Nursing). (2017). Retrieved from http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment/
“What is a Normal Heart Rate?” (2015) Retrieved from https://www.livescience.com/42081normal-heart-rate.html Task 2: Care planning Nursing Care Plan: Rosie Note: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer A reminder that all information must be referenced Nursing problem: Pain Management
Underlying cause or reason: Rosie has had falls, most recently leading to her admission to the emergency departm falls and the surgical procedures. Regarding her age, she must be feeling much pain from these events.
Goal of care
Nursing interventions/actions
Watch Rosie’s movements, monitoring her gestures, facial expressions and other impressions (Pain Management Nursing Role, n.d.).
Ask Rosie how she feels when she does certain activities (Pain Management Nursing Role, n.d.).
To help reduce the pain that Rosie currently feels
Perform massages on Rosie when she requests, especially where she feels pain.
Monitor Rosie’s wounds and stitches and dress the wounds.
Administer pain killers to Rosie appropriately (Pain Management Nursing Role, n.d.).
Rationale
By monitoring Rosie’s impressions, I will easily determine and interpret the level of pain she is undergoing, or otherwise if she feels any pain at all.
By contacting Rosie and knowin how she feels, I may learn of pai that I failed to monitor. Moreove Rosie may give me updates of how better she feels, from previous pains.
Performing scheduled massages, and monitoring Rosie’s wounds recovery will assist me to know the next best step to undertake to relieve her of the pain she feels, including administering pain killers and other prescriptions.
Nursing problem: Respiratory Care
Underlying cause or reason: During Rosie’s admission, her assessment recorded unhealthy respiratory patterns. A requires respiratory care, given that the signs may persist due her age, and cause worse health conditions.
Goal of care
To ensure that Rosie’s respiratory patterns are normalized during her stay, to speed up her recovery, and help her maintain better health.
Nursing interventions/actions
Administering oxygen to the patient at the right time, and monitoring her responses (Respiratory Examination, 2017).
Monitoring her breathing patterns and other chest patterns (Respiratory Examination, 2017).
Ensuring proper ventilation of the room she resides.
Administering drugs prescribed for her respiratory condition.
Rationale
Administering oxygen to Rosie helps her increase the SpO2 leve within her system which assists her to improve her respiratory condition.
Monitoring her breathing pattern assists in scheduling future prescriptions and appropriately determining her improvement.
Ensuring proper room ventilatio helps reduce risks of low SpO2 levels due to congestion within the room.
Drug administration assists Rosi in the recovery process.
Nursing problem: Nutrition Care Underlying cause or reason: Rosie and her supportive husband, Joe, do not have children. Moreover, they have fe their own. With their age, they find this difficult and seldom have healthy meals. Conversely, they often heat froz Goal of care Nursing interventions/actions Rationale
To provide Rosie with a balanced nutrition that feeds her body system with the necessary nutrients for building her body
Serving Rosie with balanced wellcooked meals at appropriate meal times (“Steps to Optimal Nutrition Care”, 2017).
Asking Rosie which healthy foods she prefers, including her favourite
A balanced meal that is well cooked provides Rosie with the necessary nutrients that she migh lack due to her unhealthy eating patterns while at home.
Involving Rosie in choosing her
healthily and helping her to recover speedily.
fruits, while also explaining to her the healthy foods she is served.
favourite healthy meals helps he feel that the care she receives is friendly to her.
Involving Joe, and challenging him to take the healthy diet too.
longer
Involving Joe helps the family learn new healthy eating habits and they may even learn of simp prepared foods that are healthy.
Nursing problem: Dementia Care
Underlying cause or reason: Rosie is 76 years old. She has stated that her memory is not quite good as it had be diagnosed with acopia. Certainly, Rosie’s old age has contributed to these health effects. She definitely needs car
Goal of care
Nursing interventions/actions
To assist Rosie to improve her memory, and help her successfully complete her tasks.
Reminding Rosie of basic tasks she should do, including taking drugs, bathing (if it is safe), eating, among many other tasks she can handle while she is still under the nurses’ care (“Nurses Caring for Geriatric Patients”, 2017).
Closely watching Rosie’s movements.
Carefully scheduling Rosie’s tasks and providing her with a program of the tasks she will perform, and the time she should perform the tasks (“Nurses Caring for Geriatric Patients”, 2017)
Rationale
By reminding Rosie of her scheduled tasks, she may, with time improve her memory and successfully complete tasks she assigned.
Monitoring Rosie's movements ease evaluation of her memory status and further strategizes better ways to assist her.
A schedule of the events will further assist Rosie to remember tasks that she is scheduled to perform.
Nursing problem: Psychosocial Care Underlying cause or reason: Rosie and her husband Joe seldom have social support since they have few friends. M them psychologically, or even socially. As a result, Joe and Rosie have developed unhealthy eating habits, and su conditions. Goal of care Nursing interventions/actions Rationale
To provide Rosie with psychosocial care and support while she is still under the care of nurses, and ensure that she receives this support even after being discharged.
Engage Rosie in light hearted conversations about life, including her likes and dislikes.
Register Rosie with communitybased Social group offering psychosocial support to old persons.
Helping Rosie with some tasks that may be unsafe or difficult for her to complete or even handle (“Nurses Caring for Geriatric Patients”, 2017).
Conversations with Rosie help h improve her social life which is essential to her health improvement.
The social group will assist Rosi after her discharge, providing he with psychological and social support.
Helping Rosie complete her task provides her with psychosocial support.
References Respiratory Examination. (2017). Retrieved from http://atitesting.com/ati_next_gen/skillsmodules/content/physical-assessmentadult/equipment/respiratory_assessment.html Nurses Caring for Geriatric Patients. (2017). Retrieved from https://www.jacksonvilleu.com/blog/nursing/geriatric-nursing/ Steps to Optimal Nutrition Care. (2017). Retrieved from https://www.americannursetoday.com/essence-nutrition/ Pain Management Nursing Role (n.d.) Retrieved from http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/MD_nursing.pdf Task 3: Medication management Task 4: Patient teaching Task 5: Clinical judgement and handover