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NUR250 Assessment 1 S2 2018 Project templateDo 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 isidentifiable. To access the footer, double click on the grey writing “Last name....” at thebottom of the page above. Once you have done that, double click here to come back to thispage.Information about the required line spacing and font size and type is in the Assessment 1information document in the Assessment 1 folder on NUR250 Learnline. Take a minute tocheck that this 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 project means you have read and understood theUniversity policies and procedures related to academic integrityAssessment 1 presentation guidelinesStart to write your project here. Word count is calculated from this point.
Task 1: Patient assessmentAccording to the given case study, it has been identified that David Parker wasadmitted to ward for myocardial infarction. David was initially recovering and at the time ofdischarge he was unable to attend rehabilitation program because he had work on the farm.David was experiencing breathlessness which was longer pleased by rest as it used to getworse when he was lying down. Further he also developed a cough that increased his fatigue.Vital signs at the time of admission were noted as recorded by patients are known as pulsepattern, saturation, body temperature and blood pressure Temperature 36.5oC Heart rate 118 beats per min Blood pressure 102/84 mmHg Respiration 24 breaths per min O2 saturations 92% on room air3 Specific nursing assessment which can be conducted as a priority on David’s admission toward to assess the planning of his nursing care-1. Nursing assessment of imbalanced fluid volumeNursing assessmentRationaleMonitoring and documentation ofvital signs related to blood pressure orheart rateMonitoring fluid status related todietary intakeReduces in circulation blood volumewhich can cause hypotension andtachycardia.There are many fluids which occur inbody through drinking, water in food. It isimportant to verify that service user is onfluid restraint is important. 2. Nursing assessment of Impaired gas exchangeNursing assessmentRationaleMeasuring respiratory rate, depth andefforts which includes use ofaccessory muscles.Fast shallow breathing patters. Dueto increase in respiratory rate anduse of accessory muscles.
Measuring the lungs' area of reducingventilation and auscultate presence ofadventitious sounds. Due to irregularly of breath soundswhich lead to disclose of thechances of impaired gas exchange.For David Parker it is important to modify his lifestyle and mostly related to theactivities or behaviour and emotions as all of these can increase workload on the heart. Here,role of nurses is to implement both the provisional nursing interventions for the patient’s. Asnurses should create a caring environment that lead to promote rest for patient in respect toprevent the demand for oxygen, should the service user be overactive. Smoking should beavoided in order to prevent respiratory distress that can lead to compound the eminenthypoxia (Castellan, Sluga and Sanson, 2016). 3. Nursing assessment of Activity intoleranceNursing assessmentRationaleMeasuring of physical activity leveland mobility of David ParkerMeasuring the rest pulse, bloodpressure and respirations.Consider the rate rhythm and qualityof pulse To provide baseline informationfor creating a nursing goal anddiscontinue the activity of theservice user for responding.Diet lead to play significant role in order to maintain health of patient who is sufferingfrom heart failure. Nurses need to ensure that patient is complied with only low salt and fatefree food. The food should be softer prepared which help in reducing the effort formechanical digestion. Each of the assessment will be conducted regularly in order to ensure that DavidParker health issues started improving. The above assessment is specifically significant forDavid’s care because his heart function is not working properly and adoption of nursingassessment will help in improving its heart functions.
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