Essential Nursing Care: Foundational Skills

This study material focuses on essential nursing care and foundational skills. It discusses the importance of primary and secondary surveys in patient assessment. The case study revolves around a seventy-nine-year-old man who suffered a traumatic brain injury and other health complications.

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Running head: ESSENTIAL NURSING CARE: FOUNDATIONAL SKILLS
Essential Nursing Care: Foundational Skills
Name
Institution

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ESSENTIAL NURSING CARE: FOUNDATIONAL SKILLS
Essential Nursing Care: Foundational Skills
Phase 2: collection information
Mr. Richard a seventy-nine-year old man living alone with no known relative was found
on the floor by ambulance staff after a neighbor called in. A head-to-toe assessment was done
where more about his health was known. “Primary Survey and Secondary Survey”. (2019)
indicates that primary survey which is the opening assessment and control of a patient has to be
done immediately which was done It was found that he had suffered a traumatic brain injury
when he fell. This was supported by the fact that he was confused and not able to point out date
or time and this indicated that he needed help immediately. A secondary survey which delves
more into a person's health to pinpoint what are the real threats that can form long complications
was done (Zemaitis, Planas, Shah, & Waseem, 2019). It was found that he had suffered a small
cut on his scalp across his right temporal area where blood had already clotted when the
ambulance arrived. This means he had been on the ground for some time. His leg was displaced
and this caused a fracture on the hip which required surgery. He had a scar on his sternum which
indicated that he had undergone an open- heart surgery in the past. His history of health records
also owed that he had been a smoker before the open-heart surgery eight years ago. Moreover, he
has been obese all his life which may have been the cause for the open-heart surgery. He had a
list of drugs in his wallet like Digoxin and Simvastatin which are normally used to increase the
strength at which the heart pumped blood and reduce the bad cholesterol in the body (Chen et al.,
2015). He had not used the drugs in the morning. He has the following fundamental signs;
Blood pressure 182/105 mm Hg
Pulse 102 beats per minute

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Respiratory rate of 6 breaths per minute
Oxygen saturation 89% on 4 liters nasal prongs
Temperature 34.50c
GCS 13/15 (E3, V4, M6)
Urine none
Phase 3: processing gathered information
Normal blood pressure should be between 140/90 and 120/80. His blood pressure is
182/105 which is higher (Staessen et al., 2017). High blood pressure may be brought about by
obesity. The more one is overweight the more the blood has to pump and that is why obesity
causes high blood pressure (Kotsis, Stabouli, Papakatsika, Rizos, & Parati, 2010). A normal
heartbeat per minute is normally between sixty and one hundred but his is one hundred and two
which is a little bit slightly higher. Furthermore, obesity increases heartbeats per minute which
may lead to stroke or cardiac arrest. Superfluous fat decreases respiratory rate, respiratory
muscle strength and causes an escalation in pulmonary resistance (Mafort, Rufino, Costa, &
Lopes, 2016). Thus, six breaths per minute are low since the normal respiratory rate should be
twelve to twenty-five. An oxygen saturation that is below ninety-five is normally considered a
low and Mr. Richard has a low since he has eighty-nine percent oxygen saturation. The low
oxygen level can be attributed to the surgery but in the real sense, it normally occurs when there
has been a pulmonary disease (Langley & Cunningham, 2017). Furthermore, his body
temperature was lower than the normal body temperature and this too is attested to obesity. The
large surface area due to obesity loses more heat than a normal person and that is why the
temperature is low. Even though his temperature is not normal it does not pose much of a threat

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compared to his blood pressure and pulse rate and thus the latter two will be attended to first.
Most of the medications he had in his wallet were either treatment of the blood pressure,
cholesterol or increasing the blood flow in the body. This signifies that his obesity was a real
problem and that he needs to improve in what he took in as food. His diet will mostly comprise
of vegetables and fruits and he will have to do a little bit of exercise every day to also cut on
wait. His skin was poor and dirty that means he does not take care of himself hygienically and
this may lead to a skin problem. Therefore, he will also be guided in the area of hygiene so that
any skin complications may not arise at this stage. He also has eyes that are deteriorating an
indication that he needs treatment on the same.
Phase 4: Identify the problem
Obesity has been related to age-related cataract and therefore, his ailing eyes maybe
because of his age and the fact that he once smoked in his early years of life (Turgut*, 2018).
The open-surgery he had years ago may be a product of smoking and smoking has been found to
increase the chances of one having heart disease. It also increases the chances of one being obese
which does not allow the efficient pumping and flow of blood in the body. The list of drugs
found in his wallet all point to the treatment of high cholesterol, high blood pressure, and poor
eyesight. Obesity is the main reason why he is having a lot of issues with his health. He probably
fell down the stairs because of his failing eyesight and his heavy body and the fact he is aging.
He was not able to prevent himself from falling and could not get up when he hit the floor.
Obesity usually leads to weakened hands and thus one is prone to fall (Tomlinson, Erskine,
Morse, Winwood, & Onambélé-Pearson, 2016). His Webster pack was found unopened which
indicates that he had not been taking his medication as he is supposed to. Another reason that
leads him to fall maybe because he passed out. Passing out is usually a product to failure of the

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nervous system to control blood pressure and heart rate. He also had no urine measured meaning
that his urine was less produced. His urine should increase in the twenty-four hours and hence he
will be put on a drip to add more fluids to his body. Low production of urine is always a sign of
less supply of blood to the kidney (Stoppler, 2019). Less supply of blood to the kidney was
because of the blood he lost when he slipped and injured his scalp.
Phase 5: Establish the goals
First, he has to be hygienically clean to avoid any more infections and diseases. Hence,
for the short term goals, he has to take a bath every single day without fail and establish it as a
routine. He will be informed of the dangers of not taking care of himself hygienically and helped
to do the same. His operated femur and scalp injury need to heal and that means he cannot fail to
take his medication as he has been doing with his other medications. Not only will there be a
time table to show him when to take the medication but there will also be follow-ups once he
goes back home. His blood pressure needs to go to below 150 and his respiration rate should
increase to about 15 breaths per minute. Moreover, his pulse should be at least eighty beats per
second and his oxygen saturation improve to ninety-four percent. To achieve all this, he needs to
take his medications of reducing cholesterol and blood pressure without fail at the appointed
times and thus, he will be followed up regularly on the same. His eyes have been failing and to
improve them he will have to watch out on his weight and diet in addition to the drugs he is
taking for the eyes. Since he is obese, he has to reduce weight and this will be achieved through
exercise and a good diet (Fock, & Khoo, 2013). He will also be placed on Hemodynamics
monitoring to improve his blood flow and urination (Huygh, Peeters, Bernards, & Malbrain,
2016).

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ESSENTIAL NURSING CARE: FOUNDATIONAL SKILLS
Phase 8: Reflection
Since he has been living alone, he has been dealing with loneliness and stress and that is
probably the reason why he was not taking his blood pressure medication. Holland (2018) cites
stress and depression to be related with increase in weight. The reason why he is struggling with
obese maybe because he is used to ordering fast foods since he cannot cook for himself every
time. Fast foods have been known to increase fatness (Anderson, Rafferty, Lyon-Callo, Fussman
& Imes, 2011). He would be put on cognitive behavioral therapy to help him cope with being
alone and any eating disorder. A family nurse who he can get used to would also work fine and
this would help him to feel comfortable and help him get medication on time. The nurse will
regularly go for rounds at his home to ensure he does exercises and takes a good diet while
monitoring his blood pressure and weight. The clinic can also choose to check on him regularly
on the phone to ensure he is taking medications as he is required. The lesson got from this case
study is to care wholeheartedly for the old who are sick and alone, to form a relationship with
them. This settles their mind and they can recuperate much faster. Counseling through the
evidence-based health practice would also help to explain to Mr. Richard about the dangers of
eating well and exercise especially for his age. The patient could also be assessed in the
preparedness to deal with the obesity issue with several questions. If he is ready then he should
be given direction and if he is not he should be advised strongly to start looking for healthy ways
to lose weight. It would also be good if he would join a support group in his area that can help
reduce stress and a lot of strain. I also learned that humanely treating the elderly goes a long way
in the healing process and shows ho ethical a nurse is. Working to change his temperature and
pressure is more important than the temperature since the former are very crucial. Furthermore, I

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learned that getting cues right the first time does a lot of good. Handovers should be done right
and timely too to avoid putting the patient in danger while in the hospital.

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ESSENTIAL NURSING CARE: FOUNDATIONAL SKILLS
Referencing
Anderson, B., Rafferty, A., Lyon-Callo, S., Fussman, C., & Imes, G. (2011). Peer Reviewed:
Fast-Food Consumption and Obesity Among Michigan Adults. Retrieved 4 September
2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136980/
Chen, S., Khusial, T., Patel, D., Singh, S., Yakubova, T., Wang, A., & Nguyen, T. (2015).
Digoxin Use in Modern Medicine. Retrieved 3 September 2019, from
https://www.uspharmacist.com/article/digoxin-use-in-modern-medicine
Fock, K. M., & Khoo, J. (2013). Diet and exercise in management of obesity and
overweight. Journal of gastroenterology and hepatology, 28, 59-63.
Huygh, J., Peeters, Y., Bernards, J., & Malbrain, M. L. (2016). Hemodynamic monitoring in the
critically ill: an overview of current cardiac output monitoring
methods. F1000Research, 5.
Holland, K. (2018). Are Obesity and Depression Related? 10 Things to Know. Retrieved 5
September 2019, from https://www.healthline.com/health/depression/obesity-and-
depression
Kotsis, V., Stabouli, S., Papakatsika, S., Rizos, Z., & Parati, G. (2010). Mechanisms of obesity-
induced hypertension. Hypertension research, 33(5), 386.
Langley, R., & Cunningham, S. (2017). How should oxygen supplementation be guided by pulse
oximetry in children: do we know the level?. Frontiers in pediatrics, 4, 138.

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Mafort, T. T., Rufino, R., Costa, C. H., & Lopes, A. J. (2016). Obesity: systemic and pulmonary
complications, biochemical abnormalities, and impairment of lung
function. Multidisciplinary respiratory medicine, 11(1), 28.
Primary Survey and Secondary Survey. (2019). Primary, Secondary Survey - CHEMM.
Retrieved 3 September 2019, from https://chemm.nlm.nih.gov/appendix8.htm
Staessen, J. A., Li, Y., Hara, A., Asayama, K., Dolan, E., & O’Brien, E. (2017). Blood pressure
measurement anno 2016. American journal of hypertension, 30(5), 453-463.
Stoppler, M. (2019). Low Urine Output: Check Your Symptoms and Signs. Retrieved 4
September 2019, from https://www.medicinenet.com/low_urine_output/symptoms.htm
Turgut*, B. (2018). Ocular changes and disorders associated with Obesity. Retrieved 4
September 2019, from https://www.heighpubs.org/hceo/ijceo-aid1015.php
Tomlinson, D. J., Erskine, R. M., Morse, C. I., Winwood, K., & Onambélé-Pearson, G. (2016).
The impact of obesity on skeletal muscle strength and structure through adolescence to
old age. Biogerontology, 17(3), 467-483.
Zemaitis, M., Planas, J., Shah, N., & Waseem, M. (2019). Trauma Secondary Survey. Retrieved
3 September 2019, from https://www.ncbi.nlm.nih.gov/books/NBK441902/