Nursing Care Client Assessment - Case Study

Running head: NURSING CARE 1
Nursing Care
Name
Institution

NURSING CARE 2
Nursing Assessment
Client Assessment
This is a case of a patient named Mrs. Walesa who before being admitted at a care facility had
failed to thrive and had been medically diagnosed with type 2 diabetes, a left-sided heart failure,
and osteoarthritis. She does not have any reported case of any allergic reactions according to the
provided case study. Some of the medications she is taking for her condition include furosemide,
metformin, metoprolol, docusate sodium, lansoprazole, and acetylsalicylic acid. According to the
case study, Mrs. Walesa is on a diet of soft 1800 CDA and diabetic snacks. Her vital signs
include a temperature of 37.4°C, a pulse rate of 88 bpm, shallow respiration at 25 breaths per
minute, blood pressure of 130/94 mmHg, and Saturation of oxygen measured at 86% and rises to
88% after addition of 2 liters of oxygen via nasal prongs.
Health Assessment
Psychological Variable
General Appearance/Mental State
Mrs. Walesa appears tired and is not oriented
to place or time. This implies that she has no
idea what time it is and she cannot also identify
where she is. This is an indication that her
mental health status has been affected by her
deteriorating condition. She also appears shaky
and irritable when being given her
lansoprazole. The irritability may also be an
Gastrointestinal System
She is on a diet of soft 1800 CDA that she
manages to consume 75% consistently. She is
required to take her diabetic snacks between
meals but she is reluctant in doing so. The
findings of the assessment also revealed that
Mrs. Walesa is continent of stool and daily
passes brown stool. She additionally takes
docusate sodium, a medication that is

NURSING CARE 3
indication of anxiety. sometimes used to treat constipation. This
medication is used as a stool softener to
prevent the patient from straining to have a
bowel movement (Ruston, Hunter, Cummings
& Lazarescu, 2013). This explains why she
passes medium-soft stool. She also takes
lansoprazole, a medication that is normally
used to reduce the acidity of the stomach and
treat conditions such as frequent heartburns.
Lab tests show that she has a below-average
creatinine which could be an indication of
excess fluid intake.
Respiratory System
On the assessment of the patient’s respiratory
system, it is discovered that she has shallow
respirations at 25bpm. Given that the normal
respiratory rate for an adult at rest ranges
between 12-20bpm, this could be an indication
of tachypnea which may be due to her left-
sided heart failure (Park, & Khattar, 2019).
Further assessment of her respiratory system
reveals fine crackles from the lungs which
could be an indication of lung failure.
Nervous System
She appears confused and disoriented as she
seems not to know the time or the place she is.
Her cognitive ability enables her to request to
be taken back to bed because she feels tired. It
is also visible that she is experiencing some
acute pain on her left knee that feels warm
when touched and the patella is red. She is also
able to describe the pain as she states that the
pain has significantly increased as compared to
the previous day. She additionally takes

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Laboratory tests reveal that her hemoglobin
concentration of 90mmol/l is abnormally high
which could be an indication of an impaired
gaseous exchange in the lungs.
Acetylsalicylic acid daily during breakfast.
This medication is used in pain reduction
(Schrör, 2016).
Cardiovascular System
Assessment of Mrs. Walesa’s circulatory
system reveals that her pulse rate is 88. Her
heartbeat is irregular; however, she has clear
S1 and S2. Her blood pressure is measured to
be 130/94 mmHg which is very high and may
be considered as stage 1 hypertension. Mrs.
Walesa takes metoprolol to treat her
hypertension and possible chest pains. She also
shows signs of oxygen deprivation because her
SaO2 is just 86% and rises to 88% when she is
given oxygen via nasal prongs. She also takes
furosemide that helps in preventing her body
from absorbing too much salt thus helping in
treating edema. According to Segar (2012), this
medication prevents fluid retention by allowing
the excess salt to be passed in the urine.
Urinary System
She passes foul-smelling urine that appears to
be very concentrated. She has urine
incontinence and uses Attends to help with the
problem. Laboratory tests reveal that her
albumin, sodium, and potassium levels are
within normal ranges which could be an
indication that her kidneys are in good
condition.
Musculoskeletal System
Mrs. Walesa’s ischial tuberosity region turns
Integumentary System
Her body temperature is 37.4°C which is