Identify two nursing assessment tools that you would use to develop a current profile of your client’s health status
Based on one of the case studies provided below and drawing on evidence-based literature, analyse the client’s details to identify and prioritise key health problems, related nursing goals and interventions aimed at achieving safe and quality care for that client, including discharge planning.
Your report should include the following:
Introduction (100 words)
Identify the case and outline the purpose and structure of the report.
Assessment (100 words)
Identify two nursing assessment tools that you would use to develop a current profile of your client’s health status and explain your choice.
Client’s Health Problems (350 words)
Identify THREE (3) health problems specific to your client and prioritise these problems to ensure safe and quality care of your client. Justify the prioritisation you decided.
Goals (150 words)
Based on the health problem you prioritised as the most urgent, identify 2 goals or desired outcomes for your client.
Interventions (350 words)
Identify two interventions for each of the 2 goals and provide rationales for interventions.
Discharge (350 words)
Identify at least 4 key issues the client might face after discharge. What are the strategies you are going to use to address these issues?
Conclusion (100 words)
Summarise the major points of this report, and stress the importance of the report.
Harvard Referencing System
Case study ONE
Mr Wilson, a 70 year old man, presented to the emergency department (ED) accompanied by his neighbour at 10:15AM. He looked exhausted and found it hard to talk in long sentences due to difficulty in breathing, even at rest. Mr Wilson said that he caught a ‘flu’ about a week ago, and it was not getting any better despite his drinking plenty of water and taking paracetamol. He was also feeling very tired, and did not have the energy to prepare breakfast that morning. He stated that this might be because he has not been sleeping very well at night, as he has been needing extra pillows to sit up to help his breathing.
You noticed pitting oedema on his lower legs. Mr Wilson has had several heart attacks, with the last one occurring 18 months ago. Following this, he was diagnosed with congestive heart failure. He had an echocardiogram that showed he had a left ventricular ejection fraction (LVEF) of 30%. He also has a history of hypertension, osteoarthritis and cataract in the right eye. Mr Wilson lives by himself in a two-story unit. His wife, who was the primary carer for him, died 6 months ago. According to his neighbour, Mr Wilson has been withdrawn and depressed since his wife passed away. The neighbour helps Mr. Wilson as much as he can, as Mr Wilson does not have any other family.
Case study TWO
Cheryl–Warra Allen, a 52 year old Aboriginal woman, was brought into the emergency department (ED) by ambulance with acute shortness of breath. Cheryl has had previous ED admissions since relocating to Adelaide, from the remote Aboriginal community Poonindie, 3 years ago. Her previous medical history includes Type 2 Diabetes Mellitus (T2DM), Hypertension, and end-stage kidney disease (ESKD) for which she has hemodialysis treatment 3 times per week. Cheryl says that she has missed dialysis this week due to unforeseen family reasons and her blister pack of medications show that Cheryl had not taken her medications for 3 days. Her weight, on admission to ED, was 9kg above her ideal body weight.
The on-call nephrologist orders emergency hemodialysis for Cheryl whilst the ED nurses provide respiratory support with oxygen via a non-rebreather mask, at 15L per minute. Cheryl is transferred to the Renal Ward immediately post the emergency hemodialysis treatment.
On arrival to the ward, Cheryl needs assistance to transfer from the wheelchair to the bed, where she immediately asks you lift the back of the bed up so that she can sit upright in bed. You notice that she has peri-orbital odema and the oxygen mask has left indentations on her cheeks. She also appears to be working hard to breathe and is speaking in short sentences only. Despite this, Cheryl says that she would like a cup of tea.
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