Nursing Case Study Analysis
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Added on 2019-11-20
Nursing Case Study Analysis
Added on 2019-11-20
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1Running head: NURSINGNursing Name of student:Name of university:Author note:
2NURSINGThe patient in the present case study analysis is Mr Paul Peters who had beenadmitted to the cardiac unit with the NSTEMI (Non-ST segment elevation myocardialinfarction). From the assessment of his current condition, it is noted that he is in unstablecondition and the ECG shows abnormality in heart rhythm. The correct vital statistics areT36.5, HR 88, RR 18, BP 110/70, while the oxygen saturation is 96%. His age is 50 andweighs 88 kgs. He is a factory worker and a regular smoker, with a sedentary lifestyle. Hislevel is education is low. The present section would detail the assessments to be taken for thepatient. Assessment of the cardiac system of the patient would be most crucial since thepatient has abnormal heart rhythm and he is in unstable condition. The cardiac examinationwould follow the stages of inspection, palpation and auscultation. The patient would need tobe positioned in the supine position and torso and neck would be exposed completely. Thegeneral inspection would include his status of comfort, an abnormal movement like headbobbing. The hands are to be inspected for skin turgor and temperature. It is imperative that anurse is as objective as possible while collecting patient data. Reporting the findings is verymuch essential, and the charting of the results in a clear manner is also needed (Donahue2011). The second assessment would be a central nervous system that would involve theassessment of the motor and the sensory responses of the patient. The purpose would be thedetermination of impairment of nervous system. The examination to be conducted is MentalStatus Examination. This would involve the assessment of consciousness using the GlasgowComa Scale. A Mini Mental State (MMSE) examination would be pivotal. Muscle strength isto be examined through the MRC (Medical Research Council) scale. The patient is to beassessed for muscle tone and rigidity. Any abnormal movement, such as seizures and
3NURSINGfasciculations are to be assessed along with the above mentioned assessments (Watkins,Whisman and Booker 2016). The consecutive assessments would be of the abdomen, respiratory system and therenal system. Abdomen assessment would involve inspection, auscultation, palpation andpercussion of the abdomen. The inspection would include an examination of the shape of theabdomen, abdominal masses, skin abnormalities, and abdomen wall movement withrespiration. Auscultation would detect altered bowel sounds, vascular bruits or rubs.Atherosclerosis is the common cause of alteration of arterial blood flow. Palpation refers tothe abdomen examination for crepitus of the abdominal wall, for any abdominal masses orabdominal tenderness (Lewis et al. 2016) . Assessment of the renal system, that is, kidneysand bladder are commonly performed in combination with an abdominal assessment.Auscultation is performed before percussion and palpation because these activities can lead tovague abdominal vascular sounds and enhanced bowel sounds. Assessment elements wouldinclude frequent urination, difficulty in urination and hematuria. A urine specimen is to bechecked for infection, and odour and colour. The bladder is to be palpated for any signs ofdistention of the bladder. Assessment of the respiratory system would mainly focus on theevaluation of respiratory distress. Major evidence of distress are a cough and audiblewheezing. Body temperature and respiratory rate are to be checked regularly (Considine andCurrey 2015).Since the patient is a regular smoker and drinker, his social background is also to beassessed before outlining the care plan. The regular nutritional diet of the patient is to beassessed. It is important to know whether the patient had suffered loss or increase in weightin the recent past. The Patient Centered Assessment Method (PCAM) can be the appropriatetool for assessing the complexity of the patient through examination of the healthdeterminants. The tool assesses the lifestyle behaviour of the patient, the mental well being
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