The Neurological Test of the Patient

Added on -2020-02-19

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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 disease resulting in adverse events.
Goal of care Nursing
interventions/actions
Rationale Indicators your plan is
working
To prevent
and control
the spread of
influenzawithi
n the
healthcare
facility and
the
community.
Assessment of
respiratory status,
depth, accessory
muscle usage and
breathing pattern.
Auscultation of the
lung field to check for
wheezing, crackles and
any other breath or
heart related sounds.
Infection may cause
bronchial swelling,
mucous
accumulation in air
sacs which causes
narrowing of air
passage which leads
to distress while
breathing. Care has
to be taken so that
the infection does not
spread further and
Patient is expected to
show signs of stability
and achieve
homeostasis.
The respiratory passage
of the patient should be
cleared.
The patient is expected
to have clear breathing
without any obstruction

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