Jan 76-year-old female, is being admitted to your ward from emergency department with acopia and falls for investigation following a fall at home.
Vital signs on admission: blood pressure 150/95, heart rate 110
beats per minute, respirations 20 breaths per minute, SpO2 90% on
On examination in emergency department Jan was found to have haematomas to her left eye and bilaterally on her knees and a small superficial laceration to her left eye that was sutured in emergency department. A CT of her head and x-rays shows no apparent fractures or abnormalities.
Prior to admission
Jan has been having an increasing number of falls at home over the past few months. She denies dizziness, pain or loss of consciousness contributing to the falls. She states she” just goes weak and falls down”. She reports she sometimes feels quite anxious and breathless post fall. Jan has a medical history of hypertension and hypercholesteraemia. Jan, however, is a poor historian claiming “my memory is not quite as good as it once was”. Jan lives with her supportive husband, Joe who assists her as needed. Joe states “we have always looked after each other” since coming to Australia from Poland forty years ago. They have never had children and have very few friends or social supports preferring to rely on each other.
They try to cook healthy meals a few times a week but are increasingly relying on heating frozen meals or snack foods for convenience.
Joe states he has to assist Jan a bit more than usual as she seems to be “slowing down “and is becoming increasingly tired and fatigued. He is finding it especially difficult when she falls and is having to rely on the
ambulance service to assist to get her up.
Patient assessment – 300 Words
Assessment is one of the major roles of the registered nurse and is
the first step in the nursing process to assist in planning and to facilitate mutually established goals and evaluate outcomes. In reality the nurse is continually assessing and reassessing the patient throughout the continuity of care.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice
· Identify 3 specific nursing assessments that you would conduct as apriority for Jan’s nursing care that you will undertake on Jan’s admission to your ward.
For each assessment you have identified explain:
· Why the assessment is relevant to Jan’s care
· What consequences may occur if this assessment is not completed accurately?
You recognise that Jan may require assistance addressing her fundamental care needs. Based solely on the handover you have received and using the template provided,
Address the following 5
Fundamental care needs
- safety and falls prevention and risk management
- nutrition and hydration
- personal hygiene and dressing
- dignity and privacy
- communication and education
For each Fundamental care need
Address the following
· The related nursing problem
· The underlying cause or reason that the nursing problem is related to
· Goal of care
· Specific bedside nursing interventions you will do
· The rationales for your nursing interventions and actions
· Indicators that your plan is working
Notes for Task 2 only
·Read beyond the set texts to prepare the nursing care plan. Appropriate sources students might find useful for the care plan
ONLY is information on the JBI database
·Dot points may be used in the care plan template
·Rationales must be appropriately referenced
900 words in total – approx. 180 words each Fundamental care need, Im happy to provide template x 5 – that can be typed straight on – alternatively I can transfer the information to template at later time.
Task 3 Medication Management
Three important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications, understanding the nursing responsibilities and how to monitor the patient to ensure they are responding to prescribed medications as they should.
In grammatically correct sentences and topic paragraphs
and using current, reliable evidence for practice,
Please reference from files provided – Information provided from Harvards Nurses guide to Drugs and set text ..
·Briefly explain why Jan has been prescribed:
o Atorvastatin 20mg daily
o Ramipril 10mg daily
o Aspirin 100mg daily
·Identify and explain
o The specific nursing responsibilities associated with administering each medication
o How you will monitor Jan for expected, side and adverse effects of each medication.
Nurses are in a prime role to support and encourage healthy lifestyle changes and educate patients on healthy living to reduce the risk of morbidity and mortality of hypertension and hypercholesteremia.
You recognise part of your nursing role is to provide Jan with
education on the modifiable risk factors for hypertension and hypercholesteremia during her hospital stay.
Select one (1) of the diagnoses above and, in grammatically correct sentences and topic paragraphs,
·Identify the specific information you will need to explain to
Jan about the topic AND
o Why the topic is an important aspect of Jan’s care
o How you will ensure that Jan knows and understands
why it is important and, if appropriate to the topic, what she needs to do
Clinical judgement and handover
There are two (2) parts to Task 5. 300 words in total
When removing Jan’s breakfast tray this morning you notice she has not eaten and ask her why. She states she slept badly overnight as she could not get comfortable lying down and she is feeling anxious about Joe being on his own. As a result, she is now feeling nauseous and unwell.
She denies pain apart from slight indigestion which she often gets lately but it usually goes away on its own. She is feeling irritable so you leave her to rest.
On your return you find Jan extremely agitated and trying to get out of bed stating she has to call Joe. Visually assessing Jan as you assist her back into bed you notice Jan’s skin appears very pale and slightly bluish grey. She appears dyspnoeic and slightly breathless with shallow, rapid respirations.
Her skin feels cool and moist and her ankles appear swollen.
On further assessment you find:
· Respiratory rate is 28 -32 breaths/minute
· Oxygen saturations are 84%
on room air
· Heart rate 1
· Radial pulse is weak and thready and difficult to palpate.
· Blood pressure is
90/80 mmHg but faint and difficult to detect clear margins.
In grammatically correct sentences and topic paragraphs,
o What you think is happening
o Your immediate nursing actions and interventions
o The reason for your actions and interventions
An important legal requirement of nursing practice is to effectively and succinctly communicate relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.
Once Jan’s condition has been stabilised, the doctors arrange to transfer
Jan to the Coronary Care Unit for closer monitoring and management.
Using the ISBAR format, information from the handover you initially received and the additional information above:
·Write a written handover that clearly and succinctly outlines the important information the coronary care unit needs to know about Jan
Your handover must:
·Demonstrate person centred care
·Adhere to the legal and professional nursing standards for documentation
·Be in appropriate professional language
·Contain NO abbreviations or nursing jargon
Please see attached ISBAR File
Please use my files attached from Harvards Nursing guide to Drugs 9th edition. For part 3.
·All resources should be from quality, reliable and reputable journals relevant to nursing practice and the Australian healthcare industry or reputable, reliable, professional websites.
·All resources must be dated between
2010 and 2017·
There must be at least 8
peer-reviewed journal articles and/or evidence based practice guidelines cited in your assignment.
·Do not use any health facility or local health service policies or procedures
Only 1 current Australian medication textbook (Harvards files provided)
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and 1 current Australian medical surgical nursing textbook to be referenced.