Essential Nursing Care: Foundational Skills

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

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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
Respiratory rate of 6 breaths per minute

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ESSENTIAL NURSING CARE: FOUNDATIONAL SKILLS
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
compared to his blood pressure and pulse rate and thus the latter two will be attended to first.