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NUR250 Assessment on Nursing

   

Added on  2021-04-21

18 Pages3584 Words27 Views
Disease and DisordersHealthcare and Research
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NUR250 Assessment 1 S1 2018Assignment templateIt is recommended you do not delete the heading and the information below.Please note:As indicated in Assessment 1 information, a cover sheet, title and contentspages are not requiredBefore you begin take a minute to fill in your details in the footer to ensure your document is identifiable. To access the footer, double click on the grey writing “Last name....” at the bottom of the page above. Once you have done that, double click here to come back to this page.Information about the required line spacing and font size and type is in the Assessment 1 information document in the Assessment 1 folder on NUR250 Learnline. Take a minute to check thatthis document meets those requirements. To avoid or minimise problems with formatting, it is recommended you Use the headings providedDon’t copy from another document onto this templateDon’t delete the section breaks on the documentSubmission of your assignment means you have read and understood theUniversity policies and procedures related to academic integrityAssessment 1 presentation guidelinesStart to write your assignment here. Word count is calculated from this point. Task 1: Patient assessment Jim was last one day ago and on admission, an initial assessment is done. Preliminarydiagnosis prior to admission indicates Influenza. On a problem-based focus, the keyassessments to be undertaken are on the unproductive airway clearance, an ineffectivebreathing pattern and hyperthermia. The airway clearance is ineffective, on inspection it is evident that there is copious nasaldischarge and inflammation of the tonsils. Assessment of rhinorrhoea and tonsillarinflammation serves to ensure a proper respiratory mechanism. The patency of the airwayin the case is important. A backflow of the nasal discharge could cause fluid aspiration into1Double click here to fill in this footerLast name__ _student number_NUR250 S1 2018 Assessment 1
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the lungs causing aspiration pneumonia. The unchecked tonsillar inflammation can result inasphyxia. Assessment of the pattern of breathing is crucial on admission. His airways should beinspected, the chest palpated, inspected then auscultation done to rule on the previousindication of bilateral wheezing. Adequate objective data to this account provide the on thenecessities admission especially on the oxygen administration. In spite having good airentry, there is a possibility of pulmonary oedema and reduced oxygen perfusion. The initialoxygen saturation is at 94% of recommended (90-100%). Ineffective scrutiny of this vitalcould end up in shortness of breath and eventually culminate in respiratory distress andeventually an airway shutdown. Temperature is a crucial assessment focus. It is previously shown that the patient hadhyperthermia with a body temperature of 38.3°C .This is an evidence of fever and validatedby the pulse rate of 105 bpm. There is also increased sweating. Assessment of temperatureis necessary to ensure that appropriate measures are taken on admission including fluid andelectrolyte replacement and ensure there is adequate hydration. Unmonitoredhypothermia can cause accelerated reduction in the metabolism and reduction in the levelof consciousness (Yagil, R., Etzion, Z., & Oren, A. (1983)). There is also a possibility of anincreased cardiac output, heart rate and eventually risk of a myocardial infarction.2Double click here to fill in this footerLast name__ _student number_NUR250 S1 2018 Assessment 1
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3Double click here to fill in this footerLast name__ _student number_NUR250 S1 2018 Assessment 1
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Task 2: Care planningNursing Care Plan: JimNote: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer. Do not remove text from thetemplate.A reminder that all rationales must be referenced Nursing problem: Risk of spread of infectionUnderlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immunocompromised patients in thehospital setting are at higher risk of contracting disease resulting in adverse events.Goal of careNursing interventions/actionsRationaleIndicators your plan is workingTo prevent and controlthe spread of influenzawithin the healthcarefacility and thecommunity.Isolate the client in a room withmonitored negative air pressure,with the room door closed, and theclient remaining in the room.Always wear appropriaterespiratory protection when youSuch set of precautions are meantto prevents airborne transmissionand contact transmission of thedisease. (La Rosa, G., Fratini, M.,Libera, S. D., Iaconelli, M., &Muscillo, M. (2013).There are no signs of infection noticedThe hospital staff, patient and his visitorspractice proper hand washingThe patient remains isolated in a room withmonitored negative air pressure.4Double click here to fill in this footerLast name__ _student number_NUR250 S1 2018 Assessment 1
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