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.
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)
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 problem
o •The underlying cause or reason that the nursing problem is related to
o •Goal of care
o •Specific bedside nursing interventions you will do
o •The rationales for your nursing interventions and actions
o •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 database
o •Dot points may be used in the care plan template
o •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 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 Rosie for expected, side and adverse effects of each medication.
(300 words, 10 marks)
Task 4: Patient teaching
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 Rosie 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 Rosie about the topic
o Why the topic is an important aspect of Rosie’s care
o How you will ensure that Rosie knows and understands why it is important and, if appropriate to the topic, what she needs to do
(200 words, 10 marks)
Task 5: Clinical judgement and handover
There are two (2) parts to Task 5.
When removing Rosie’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 Rosie extremely agitated and trying to get out of bed stating she has to call Joe. Visually assessing Rosie as you assist her back into bed you notice Rosie’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 140 beats/minute.
• •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 Rosie’s condition has been stabilised, the doctors arrange to transfer Rosie 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 Rosie
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