Identify o What you think is happening o Your immediate nursing actions and interventions o The reason for your actions and interventions
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 air
On 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.
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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.
For 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)
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Identify o What you think is happening o Your immediate nursing actions and interventions o The reason for your actions and interventions was first posted on August 2, 2019 at 12:41 pm.
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