Running head: MEDICAL ASSESSMENT Medical Assessment Name of Student Name of University Author Note
1MEDICAL ASSESSMENT Assessment 1: Patient Assessment The patient, Jim is an elderly 58 year old male who seems to be undernourished suggestive of underprivileged living condition. He seems to have elevated body temperature indicating feverish conditions along with inflammation and oedema in tonsils, ear and pharynx. He is having incessant clear nasal and muscle pain all of which suggests flu like clinical symptoms (Essen et al., 2014). The discharge sample is sent to the microbiological lab for diagnosis and the results have yet to arrive. The patient’s heart rate is marginally elevated to 105 beats per minute (BPM) and respiratory rate (RR) is also seemingly normal, 18 respirations per minute (RPM). The breathing of the patient is still difficult with bilateral wheezing with no crackles visible in lungs, so no symptoms of bronchitis are observed. The cardiac output of the patient has come down to threshold value and no sings or murmuring or gallops is observed. The blood pressure of the patient is very high, 158/86mmHg, this could be due to hypertension, which the patient seems to have a previous history of, but does not take medication in spite of being previously prescribed (Bromfield & Muntner, 2013). Although the patient came in the day before with chest pain, muscle soreness, fatigue and malaise which seemed to have been controlled down but the patient still has rhinorrhea and muscle tenderness. The neurological test of the patient seems to be positive; Jim seems alert and oriented and is responding to the parameters of Glasgow Coma Scale (GCS) properly. The patient seems to be sweaty, which could be due to his hypertensive habit. After his hospitalization, oseltamivir is commenced to on suspicion of influenza (Dobson et al., 2015). Jim used be a vigorous smoker but due to his poor economic conditions, he cannot afford much cigarette, but still smokes 5-10 sticker per day.
2MEDICAL ASSESSMENT Assessment 2: Care Planning
3MEDICAL ASSESSMENT Nursing problem:Risk of spread of infection Underlying cause or reason:Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immuno-compromised patients in the hospital setting are at higher risk of contracting diseaseresulting in adverse events. Goal of careNursing interventions/actions RationaleIndicators your plan is working Toprevent andcontrol the spread of influenzawithi nthe healthcare facilityand the community. Assessmentof respiratorystatus, depth,accessory muscleusageand breathing pattern. Auscultationofthe lung field to check for wheezing, crackles and anyotherbreathor heart related sounds. Infection may cause bronchialswelling, mucous accumulationinair sacswhichcauses narrowingofair passage which leads todistresswhile breathing. Care has to be taken so that the infection does not spreadfurtherand Patientisexpectedto show signs of stability andachieve homeostasis. The respiratory passage of the patient should be cleared. The patient is expected to have clear breathing without any obstruction
End of preview
Want to access all the pages? Upload your documents or become a member.
Oxygen therapy in the pulmonary artery to lower the hypoxic condition in the pulmonary arterylg...
Medical Surgical Nursing Assessmentlg...
Emergency Nursing Case Studylg...
Chronic Obstructive Pulmonary Diseaselg...
NUR250 Medical Surgical Assignmentlg...
Pathophysiology and Pharmacology Relating to a Caselg...