Identify 3 specific nursing assessments that you would conduct as a priority for Rosie’s nursing care that you will undertake on Rosie’s admission to your ward.
Rosie, 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 room airOn examination in emergency department Rosie 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 Rosie 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.
Rosie has a medical history of hypertension and hypercholesteremia. Rosie, however, is a poor historian claiming “my memory is not quite as good as it once was”.Rosie 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 Rosie 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.
Assessment 1:
Based on the handover you received at the beginning of your shift today, other information included below and current reliable evidence for practice, address the following 5 tasks.Do not make up or assume information in relation to or about Rosie. Only use what you know from the information you received today.
Task 1: Patient assessment
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 re-assessing 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 a priority for Rosie’s nursing care that you will undertake on Rosie’s admission to your ward.ANDFor each assessment you have identified explain:• •Why the assessment is relevant to Rosie’s care.• •What consequences may occur if this assessment is not completed accurately?(300 words 10 marks)
1. Task 2: Care planning
You recognise that Rosie may require assistance addressing her fundamental care needs.Based solely on the handover you have received and using the template provided, select five (5) fundamentals of care from Week 1 learning materials and develop a plan of care for each one identifying:o •The related nursing problemo •The underlying cause or reason that the nursing problem is related too •Goal of careo •Specific bedside nursing interventions you will doo •The rationales for your nursing interventions and actionso •Indicators that your plan is working
Notes for Task 2 only•Read beyond the set texts to prepare the nursing care plan. Appropriate resources students might find useful for the care plan ONLY is information on the JBI databaseo •Dot points may be used in the care plan templateo •Rationales must be appropriately referenced (900 words 40 marks)
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,•Briefly explain why Rosie has been prescribed: o Atorvastatin 20mg dailyo Ramipril 10mg daily o Aspirin 100mg daily
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