Order Description

 

Jake Taylor is a 55 year-old male roof gutter guide installer, admitted to ED via ambulance following a high fall (2 metres) from the roof.

His PHx includes: IDDM, HT, Obesity, Hyperlipidaemia, IHD, Angina, Ex-smoker and he enjoys two cans of beer every day.

Meds: Lipitor 20mg – daily; Anginine ½ prn; Lantus 53unit – mane; Metoprolol 25mg BD.

X-ray in ED confirms he has a #L) femur.

He has just been admitted to your ward at 0900. You have been asked to admit Malcolm, by undertaking a comprehensive physical assessment.

He is complaining of pain in his abdomen & L) shoulder region. He is also complaining of a “headache”.

PART 1

Using the System based assessment outline the following:

1. Prioritise the nursing assessment from most urgent to least urgent, using the system assessments (i.e, CNS, CVS, Resp etc…). Each assessment must be supported with rationales clearly stating why you are conducting the assessment for the patient relating back to the patient’s condition. The rationale also need to be support by a reference (evidence based practice) published within the last 5 years.

 

For example:

Respiratory Assessment: The respiratory assessment concentrating on respiratory rate and chest auscultation would be required for this patient as currently patient is cool to touch and the patient’s lip turning blue. Gulanick & Myers (2014, pg. 201) states that “Cool, pale skin maybe a secondary to a compensatory vasoconstriction response to hypoxemia. As oxygenation and perfusion becomes impaired peripheral tissues become cyanotic”.

Then explain why you are concentrating on respiratory rate and chest auscultation. By conducting these assessments what can you confirm or eliminate maybe the cause of patient’s signs and symptoms.

PART 2

One hour after your initial assessment: 10:00AM, you assess Mr Taylor’s vital signs. You find he is distressed and complaining of L) sided chest pain. He tells you “I feel terrible; I think I’m dying and my heart feels like it coming out of my chest”

1. Based on Mr Taylor’s current presentation, please identify the essential & immediate assessment & immediate interventions that is currently required.

2. Provide/Explain rationale behind your assessments and interventions. This must be supported by current and reliable nursing evidence based literature.

3. Outline at least 2 actual and 2 potential nursing complications relating to his current presentations at 10:00AM and why?

PART 3

Based on your finding, develop a holistic nursing care plan for Mr Taylor. This nursing care plan should include the information gained in Part 1: the patient initial reason for admission to ED, take into consideration his past history in your assessments.

It must include

• 7 actual nursing problems
• 3 potential nursing problems, with interventions and rationales and evaluations for each nursing problems.

You must use the “Example of a care plan” provided below.

PART 4

Discharge Planning

Based on all of the above information, provide at least 4 nursing educational requirements with rationales for each that you need to provide Mr Taylor prior to, and on discharge.