Clinical Assessment and Planning PDF

Running head: CLINICAL ASSESSMENT AND PLANNING 1
Clinical Assessment and Planning
Student’s Name
Institutional Affiliation

CLINICAL ASSESSMENT AND PLANNING 2
Case study 1
1 (a) Factors to consider before and after clinical assessment
Before the assessment, the nurse should check at the status of health of an individual. A
critically ill individual requires an immediate assessment. The age factor is critical for evaluation
(Ervin, & Kulbok, 2018). Additionally, the nurse should gauge the mental capacity of the patient.
After the assessment, the physician should look at the differences in response between the young
and old patients. Furthermore, the nurse should ask for the occupation of the patient.
(b) The psychological factors include the: relatives and friends of the patient, nurses, and
healthcare network (Ervin, & Kulbok, 2018). Mr Bott leaves alone since the wife is late and the
son is away. The nurse attending to him should be competent enough to carry out final
assessments. The system of healthcare needs to have an array of treatment options that the
patient can decide the mode of care.
(c)
Temperature
Mr Bott's temperature is 36.5º C whereas the average body temperature is 37º C (Al-Ali,
Diab, Kiani, Kopotic, & Tobler, 2016). His temperature is within the normal range.
Pulse
He has a rate of 120 beats per minute. The standard rate ranges from 60-100 pounds in a
minute (Al-Ali et al., 2016). His records show a pulse rate that is higher than usual.
Respirations
His reading is 24 beats per minute. The normal range is 12-20 beats in a minute (Al-Ali et
al., 2016). Therefore, Mr Bott's respiration rates are higher than the normal.
Blood pressure

CLINICAL ASSESSMENT AND PLANNING 3
The average blood pressure ranges from 120/80 mmHg to 140/90 mmHg (Al-Ali et al.,
2016). Mr Saheed has elevated blood pressure of 180/90 mmHg.
Oxygen Saturation
The standard rates of oxygen levels range from 70 to 100mmHg (Al-Ali et al., 2016). Mr
Saheed has upper quartile oxygen saturation levels. The readings indicate 94mmHg.
2. Neurological observation and Assessment
I would collect the following data during my inspections:
Firstly is the conscious level of Mr Bott. I would ask him if he knows where he is and
who brought him to the hospital. Furthermore, I would slowly open his eyes to examine the level
of activity of the pupil. I would ask him random questions to gauge his response. Additionally, I
would slowly touch his forehead and note whether he is aware of the primary stimuli that I have
generated or otherwise. I would wave my hands in front of his eyes to gauge whether he can
detect my hands and what I am doing.
In the neurological assessment, I would find out which sensory organs are not functioning
correctly. I would look at the exact location of the neurological problem. A good scenario is
determining the part of the brain that the infection has affected (Powers et al., 2015). After
gauging those areas, I would come up with appropriate diagnostic and treatment strategies. I
would then screen for any signs of abnormal conditions in Mr Bott. I would then document my
findings for future references. Additionally, I would test the state of his mind and look at the
general nervous system. Moreover, I would gauge the strength of the muscles and look at the
reflex action.
3. The age: Mr Bott's is of advanced age, nothing can reverse his age
Blood pressure is high; an exercise is a good option for reducing hypertension

CLINICAL ASSESSMENT AND PLANNING 4
The temperature is average and should remain untouched.
Exercise can also normalise the respiration rate
The oxygen rate is reasonable. The rate needs maintenance
The pulse rate is higher than usual. Physical regiments lower the rate to average figures.
4. Steps in emptying and changing the Colostomy bag
The nurse needs to obtain the necessary tools to carry out the emptying process. Firstly,
the nurse opens the bag’s Clamp and cuff out its tail. Secondly, the physician transfers the
components of the Colostomy bag into a clean basin or pit latrine (Ambe et al., 2018). The nurse
should note down the pattern size of the stoma (Ambe et al., 2018). The nurse should trace the
boundaries of the hole and carefully remove a small part to come up with an opening (Ambe et
al., 2018). The next step involves the removal of backing material out of the wafer (Ambe et al.,
2018). Furthermore, the nurse should get rid of the previous bag. The nurse throws away the old
container. The new skin underwent inspection and washed without detergents (Ambe et al.,
2018). The nurse then dries the new bag. The nurse then applies paste at the bottom of the bag
(Ambe et al., 2018). Then add deodorant. Get rid of the remaining items used during the
emptying and replacing exercise.
5. (a) Factors associated with immobility
 Visual impairment
Loss of sight prevents an individual from moving from one place to the other. One cause of
sight loss is the stroke. The onset of stroke restricts blood flow to the brain (Balasubramanian,
Melendez-Calderon, Roby-Brami, & Burdet, 2015). Therefore, the CNS cannot receive the
necessary nutrients to perform its functions. Moreover, the brain lacks oxygen to carry out its