Analyzing and Responding to Client Health Information
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Added on 2023/01/06
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This document provides a comprehensive guide on how to analyze and respond to client health information. It covers the importance of vital signs, assessments, and documentation. The document includes different scenarios and their potential complications. It is suitable for healthcare professionals and students.
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HLTAAP003 Analyse and respond to client health information
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TABLE OF CONTENTS ASSESSMENT TASK 1.................................................................................................................3 REFERENCES................................................................................................................................8
ASSESSMENTTASK1 Section1:-Scenario Scenario 1: At 1315, Emma Jones, 32, is admitted to your ward from home (via the emergency department) with a left Colle’s fracture, (fractured left distal radius) following a fall; she has a past history of childhood measles, wisdom teeth extraction, and morphine allergy; she is on the oral contraceptive pill, and no other medications. Her left arm is being elevated with a sling and supported by a pillow to reduce swelling, but her fingers and hand are puffy. On arrival to the ward she has manageable pain; she is fasting prior to the surgery onherwrist,withherscheduledtheatretimefor1600.Herhusbandispresent. Q1. What observations does Emma need on admission and Why? Answer- ThefollowingobservationsdoesEmmaneedsonadmission- • respiratory rate: She has morphine allergy so it is important to check respiratory rate because it leadsrespiratorydepression. • heart/pulse rate: It is important in emergency situation to check that heart is pumping sufficient blood as well as supports in finding causes of symptom like Emma’s finger and hand are puffy. • blood pressure (systolic, diastolic and mean): It is important to check cardiovascular and homeostasisofEmma. • temperature: Body temperature is essential to check because wide number of diseases are characterized by a minor and wide change in body temperature (Garibaldi & Olson, 2018). • SpO2, pulse oximetry: It is an oxygen saturation that is used to measure of the amount of oxygen carrying through HB in respect of amount of HB is not carrying oxygen. As know body requires specific level of oxygen in the blood otherwise it will no function proficiently. • BGL: It is essential to analyze glucose level in body because if blood glucose level is low that means patient will lose the ability of think and function normally. If glucose level is high that means patient suffer from diabetes. In Emma’s case study she is suffering from swelling, colle fracture etc. and she has allergy of morphine and takes oral contraceptive. These above-mentioned checkups will clear reason behindofallthesediseases. Q2. Apart from the mild swelling noted in the emergency department handover, all Emma’s admission vital signs are unremarkable. Where would you document them?
Answer- Clinical and Physical examination are the nursing documents that would handover to Emma’shusbandinhospital. Q3. When you checked Emma’s wrist and hand, you noticed that her wedding ring was tight because of the swelling?. Answer: During physical examination of Mrs. Emma’s wrist and hand, then I noticed that a ring was tight in her index finger because of the swelling. Q4.Howdoyouactionthisandwhy? Answer- It denoted that Emma has edema that’s why her wrist and finger were swelled. In this state, I will use traditional method priorly to remove ring but when ring will not remove by traditional method like pulling and oiling then I will give surgical treatment for the removal of thering(Onguti,Mathew&Todd,2018). At 1455 Emma’s husband comes up to you at the nurses’ station to tell you that she is experiencingworseningpain. Q5.WhenyouassessEmma,younoticethattheswellingismuchworse.Whatother assessmentsshouldyoudo?Whatareyouassessingfor? Answer- Cold therapy system (like icepacks) is one of the best method to compress swelling and supports to reduce swelling by preventing blood flow to the area and slows down cellular metabolism (Stone, 2016). Lymphatic massage on the affected area can support to move excess fluid through which swelling is much worse. Keep affected limb upper to heart for adequately blood circulation. Avoid tight clothing and avoids extreme temperature. Emma tells you her pain is increasing from her elbow down to her fingertips and gradually getting worse over the last half hour, and is now severe, from her mid-forearm down. She says her skin feels tight, and her hand is now pale, cool, too swollen for her to wriggle her fingers, she has pins and needles in her fingertips and reduced sensation; when you press on her fingertips, it takesseveralsecondsforthecolortoreturn. Q6. What is most likely causing Emma’s increased pain and these new signs? Answer- Arthritis is the major cause of increasing pains from elbow down to fingertips. Mrs. Emma already has collie’s fracture so pain is increasing at high level. The most common symptoms of arthritis are numbness, tingling and pains in the hand. That’s why when press on Emma’s fingertips that takes fewer seconds for the color to return (De Backer & Vieillard-Baron, 2019).
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Q7. How should you action this? Answer- Pain medication i.e. acetaminophen, ibuprofen can support relive occasional pain in muscles and joints. Regular exercise and nutritious diet are recommended to Mrs. Emma. Non- pharmacological therapies and patient education and support etc. also recommended to the Mrs. Emmathatwillsupporttorelivepain(Yadav&et.al.,2020). Emma returns from theatre at 1745, following an open reduction and internal fixation (ORIF) of her fractured wrist, and a fasciotomy (a surgical incision into the fascia tissue to release pressure). Any surgery, however well performed, is an insult to the body and results in trauma and,potentialcomplications. Q8. In addition to pain, what two complications is Emma at greatest risk of, and how would they most likely manifest? Answer- Open reduction and internal fixation (ORIF) is a type of strategy that is used to stabilize and heal a broken bone effectively. Fasciotomy is a type of surgical procedure or can say it is a limb-saving procedure that used to treat acute compartment syndrome. Two surgeries have done of Mrs. Emma due to this her elbow and hand pain have increased too much. The major risks are post-surgical infections and nerve damage of these surgeries. These complications would likely tomanifestaftersurgerieslikeORIFandfasciotomy(Barca&et.al.,2016). Scenario 2: Judith Mason is a previously well 79-year-old woman who has been living independently at home. According to her son, who has brought her into hospital, she was her usual self when he spoke with her last night, but when he visited her this morning she was confused, disoriented,andhallucinating. Hervitalsignsare:T37.8C,RR18,SaO297%onair,PR88,BP105/70⁰ Her GCS is 13: she obeys directions, and spontaneously eye-opens, but is disoriented to time and place; her pupils are equal and reactive, her limbs have equal strength, and she hasnodifficultyspeakingorswallowing. Mrs. Mason’s medical history is confined to four healthy pregnancies, an appendectomy when she was 20, and a fractured ankle in 2005 after a mechanical fall. She takes no regular medication or supplements, was a light smoker until 1974 (when she quit), and she drinks a glass of wine most days. She has been diagnosed with a urinary tract infection. Q2. Think about the information given in the case study – which, if any, of her assessments are abnormal or unexpected? What is the most likely cause of these alterations?
Answer- All assessment of the patient was normal such as body temperature, respiratory rate, oxygen level, pulse rate and blood pressure. Confused, disoriented and hallucinating are the symptoms of urinary tract infection. Disoriented with time and place indicates that Mrs. Mason is suffering from Delirium that caused by sudden abnormal brain functioning. Q3. Looking again at Mrs. Mason’s neurological assessment, what are two other conditions that couldcausetheseresults?Whyaretheyunlikely? Answer- Delirium and UIT are the major reason behind of Mrs. Mason’s condition. These diseasescausedbyneurologicalproblem. Q6. When you help Mrs. Mason transfer from the emergency trolley to her bed, you notice that sheisunsteadyonherfeet. a) What additional assessment do you need to perform? Answer- Clinical examination is mandatory in this state because Mrs. Mason’s unable to steady on her feet that denotes, it may possible her feet never has destroyed. 7. Name two types of documentation you need to complete for Mrs. Mason on admission? Answer- Admission form and assessment documents have to complete before admission of Mrs. Mason. In this form includes overall history of client like name, age, medical history, physical examination and clinical examination that supports health professionals to understand situation ofMrs.Emma(Bellato&et.al.,2018). Scenario 3: Vikram Singh presents to the emergency department with 24/24 of nausea, vomiting, abdominal cramps, and diarrhea; he is 23, has no significant history, and is not taking any medicationsorsupplements. Hisvitalsignsare:T37.4,HR110,RR16,BP105/70,SaO297%onair. His girlfriend Jasmine is with him and tells you she had the same symptoms a day or so ago,thoughnotasseverely,andfeelsfinenow. Q2. What is the main issue for Vikram? How would you assess this? Answer- Viral gastroenteritis is the reason behind of the abdominal cramps, nausea, watery diarrhea and vomiting. This infection causes by intestinal infection (called stomach flu) that occurs through contact with infected person or ingestion of contaminated water or food. I would assess this infection by physical examination that will help me to determine etiology of gastroenteritis and will access degree of dehydration. Physical examination test includes pulse rate, BP, body weight, body temperature etc. that provides severity of the health condition. Q4. Name two types of nursing documentation needed. Answer- An admission form is the major nursing documentation in which provide brief information related to patient like client’s status, age, name, reason of admission, initial
instruction for the patient’s care. An assessment form is another nursing document in which includes client’s information i.e. psychological, sociological, spiritual status etc. are recorded by licensed Registered Nurse (Flanigan & et.al., 2018). These documentations are highly needed before admitting Mr. Vikram.
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REFERENCES Books and Journals Garibaldi, B. T., & Olson, A. P. (2018). The hypothesis-driven physical examination.Medical Clinics.102(3). 433-442. Onguti, S., Mathew, S., & Todd, C. (2018). Communication and ethics in the clinical examination.Medical Clinics.102(3). 485-493. De Backer, D., & Vieillard-Baron, A. (2019). Clinical examination: a trigger but not a substitute for hemodynamic evaluation. Yadav, D., Bali, H., Mishra, R., Kandel, L., Khanduri, N., Tripathi, S., & Singh, S. K. (2020). Effect of Local Anaesthesia with and without Adrenaline on Blood Pressure, Pulse Rate and Oxygen Saturation-A Comparative Study.Journal of Nepalese Society of Periodontology and Oral Implantology.4(1). 18-21. Barca, I., Colangeli, W., Cristofaro, M. G., Giudice, A., Giofrè, E., Varano, A., & Giudice, M. (2016). Effects of cold therapy in the treatment of mandibular angle fractures: hilotherm system vs ice bag.Ann Ital Chir.87. 411-416. Bellato, E., Fitzsimmons, J. S., Kim, Y., Bachman, D. R., Berglund, L. J., Hooke, A. W., & O’Driscoll, S. W. (2018). Articular contact area and pressure in posteromedial rotatory instability of the elbow.JBJS.100(6). e34. Flanigan, P. M., Jahangiri, A., Weinstein, D., Dayani, F., Chandra, A., Kanungo, I., ... & Berger, M. S. (2018). Postoperative delirium in glioblastoma patients: risk factors and prognostic implications.Neurosurgery,83(6), 1161-1172. Stone, J. (2016). Functional neurological disorders: the neurological assessment as treatment.Practical Neurology.16(1). 7-17. Mochizuki, K., Shintani, R., Mori, K., Sato, T., Sakaguchi, O., Takeshige, K., ... & Imamura, H. (2017). Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single‐center, case–control study.Acute Medicine & Surgery.4(2). 172-178. Mochizuki, K., Shintani, R., Mori, K., Sato, T., Sakaguchi, O., Takeshige, K., ... & Imamura, H. (2017