Hlt54115 Nursing : About Health Assessment Answers
revise essential guidelines for writing nursing plans of care
revise factors that the nurse must consider when setting priorities and selecting nursing interventions
revise the purposes of establishing patient goals/desired outcomes
revise the process of selecting nursing interventions
review your understanding of using the Nursing Interventions Classification for planning care, within the context of Australian nursing and expected competency standards complete a plan of care for a child patient.
Identify multidisciplinary team members involved in the discharge planning of an elderly patient
Identify the positive and negative approaches to discharge planning for an elderly patient evaluate suitable approaches to care for an elderly patient in hospital evaluation your learning for the topic.
Answer:
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Care Plan | ||||
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Overview/Pathophysiology |
Health care setting |
Assessment |
Diagnostic tests (and explanation of these | |
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The tonsillitis is the common disease, which affects most of the children. They experience the bouts of tonsillitis. Most of the studies showed that the main reason of the tonsillitis can be the snores and the infection in throat. From the previous health history of Aaron, it is seen that he has otitis media and at the age 5, he suffered from varicella that is chicken pox. At the age 2, 3 he has undergone the surgical history of insertion of grommets. He snores during sleep and day by day the problem is increasing.
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Aaron received the treatment under the ENT specialist. At first, he got the primary care form the GP and then he was referred to the ENT specialist, MR. Watchman. After various tests, the physician suggested about the operation. The Nurse, Nadia guided Aaron and his mother about the pre operative care and post operative care. |
On post- operative condition, the health of Aaron was not good. The responsible nurse performed the necessary tests to check the condition of Aaron. Mr. Watchman, the ENT specialist suggested about the obstructive sleep apnoea to check the necessity of the surgery. The result of the test showed that the condition of the Aaron was not good and he needed the tonsillectomy. |
obstructive sleep apnoea test- it is the test that helps to check the condition of tonsillitis and necessity of operation. With the test, the physician suggested the oral antibiotics that are penicillin. Moreover, the GP suggested to take rest and adequate fluid to maintain the fluid balance of the body. The result of obstructive sleep apnoea showed that he had the symptoms of obstructive sleep apnoea (Barbara, Glenora and Audrey 2008). However, the operation has various risk factors that were explained to Aaron and Gillian. | |
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Signs and symptoms: |
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Physical assessment: At the time of admission to PACU his tympanic temperature was 36.1° c and the heart rate was 98 beats per every minute. His respiratory rate became 14 breaths per minute. his blood pressure falls to 105/ 58. The pain score was 6/10. He had problems in normal breathing. Hence, Hudson musk was used so that he can breathe normally. 96% on 6 L/ min of oxygen was provided.
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NURSING DIAGNOSIS: Acute Pain | ||||
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Related to: nose, ear and throat harmed due tonsillitis and had to go through tonsillectomy for the recovery. | ||||
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Desired outcome: Use of the proper analgesics as well as participation of the non- pharmacological measures, | ||||
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Assessment/Interventions: |
Rationales: | |||
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Assess the pain description of Aaron
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Prior assessment of the wound aetiology that is crucial for the identification of the nursing intervention. | |||
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Acute pain related to the tonsil tissue swelling |
Systemic inspection to identify the impending problems | |||
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Anxiety related to the discomfort
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Reducing the shear and the friction and use the lift devices, foam wedges, pressure- reducing devices, pillows in bed. | |||
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High risk of infection
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Transfer the patient with the care for protecting against adverse effects of the external mechanical forces. This can include shear, pressure, and friction. | |||
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Lack of knowledge about diet |
The validated risk- assessment tool like liquid diet to reduce the risk related to the diet (Berman et al. 2014.). | |||
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NURSING DIAGNOSIS: Fatigue | ||||
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Related to: reduced production of metabolic liveliness after surgery, greater than before needs for the energy, distorted body chemistry due to tonsillectomy, irresistible emotional demands | ||||
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Desired outcome: Carry out all the daily activities as per the ability of the patient. The patient can achieve the improved sense of the enrgy. | ||||
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Assessment/Interventions:
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Rationales:
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References
Ackley, B.J., Ladwig, G.B. and Makic, M.B.F., 2016. Nursing diagnosis handbook: an evidence-based guide to planning care. Elsevier Health Sciences.
Barbara, K., Glenora, E. and Audrey, B., 2008. Fundamentals of nursing: concepts, process and practice. Sta Edition prentice hall Health.
Berman, A., Snyder, S.J., Kozier, B., Erb, G.L., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N., Moxham, L., Park, T. and Parker, B., 2014. Kozier & Erb's Fundamentals of Nursing Australian Edition (Vol. 3). Pearson Higher Education AU.
Doenges, M.E., Moorhouse, M.F. and Murr, A.C., 2014. Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis.
Gulanick, M. and Myers, J.L., 2013. Nursing care plans: nursing diagnosis and intervention. Elsevier Health Sciences.
Potter, P.A., Perry, A.G., Stockert, P. and Hall, A., 2016. Fundamentals of nursing. Elsevier Health Sciences.
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