Explain the rationale in taking routine observations on a patient that has returned from theatre.

Task Case Study
Assessment steps

⦁ Read the history
⦁ Make notes regarding any acute changes, variances in vital signs and other outstanding data.
⦁ Listen to interview. This is a 13-minute recording.

Task 1
Step 1 & Step 2
Case study

Elisabeth R (known as Liz)
Aged 58 years
Female.
Enrolled Nurse

Situation

58-year-old female presented into the emergency department with neurological changes, having had an unresponsive episode at home.
She had just returned from an overseas vacation and has become unwell.

Acute Preliminary health assessment.

⦁ Temperature: 36.2

⦁ Pulse: 102 irregular

⦁ Respirations: 22

⦁ BP 160/95

⦁ O2 saturations 94%.

⦁ On presentation to the hospital, she was complaining of nausea, headaches, blurry vision, and was disoriented to time and place.

⦁ Glasgow coma scale (GCS) is EO 3, VR 4, BMR 6 total 13.

Background

Liz lives at home with her husband Marcus. They have two adult children that do not live close.
She had been treated for breast cancer 5 years ago. Her treatment consisted of radiation and chemotherapy and she has not required any further treatment.
At present she is not taking any regular medication only paracetamol for her headaches.

Step 3.

Listen to the audio and follow direction as per the student instructions. This is on the Moodle site.

Question 1

From Liz’s acute preliminary health assessment, identify and discuss two (2) ‘actual’ health problems that you would share with the Registered Nurse and other members of the Health Care Team.
Research and Reference

Approx. 100 words.

Question 2

Using you 2 actual health issues discuss two (2) ‘potential’ health issues regarding Liz’s acute health problems that you would also share with the Registered Nurse and other Members of the Health Care Team.

Research and reference

Approx. 100 words.

Question 3

Using one (1) of Liz’s above health problems, you identified in Q1 or Q2, discuss the pathophysiology of this condition and its clinical manifestations.
Research and Reference

Approx.50 words.

Question 4.

In relation to the list below, explain to Liz and her family two (2) potential physical impacts, regarding each of her acute health problems (6 in total)
Write this as a narrative.

Describe in appropriate medical and professional terminology.
⦁ Dehydration from vomiting,
⦁ Falls due to neurological changes and
⦁ Complications of bed rest.

Research and Reference
Approx. 100 words.

Question 5

Explain to Liz and her family two (2) psychological impacts, regarding her health condition that may impact on her daily living activities.
Write this as a narrative.

Research and Reference

Approx. 100 words.

The surgeon has explained to Liz that she is having emergency surgery due to her condition. She will be having a general anaesthetic and returning to the intensive care unit post-operatively for monitoring.

Liz has returned from theatre. Her observations are being taken every 30 minutes and now she is awake. She has a slight headache but no nausea or vomiting.
She is conscious and conversing.
Acute Secondary health assessment.

Vital signs are:

⦁ Temperature 36.5c
⦁ Pulse 64 BPM
⦁ Respirations 18 RPM
⦁ Blood pressure 120/75
⦁ O2 saturations 93% RA
⦁ Pain score 5/10

Question 15

Review the above data.

Using critical thinking and problem solving, prioritize your nursing interventions to reflect the changes in Liz’s condition.List the data changes and the rationale behind your decisions.

In your own words.

(100 words)

Question 16.

Liz is experiencing pain.
Discuss two (2) strategies you can use to promote postoperative comfort? E.g., Strategy is a plan of action: I plan to…

Discuss two (2) nursing care actions to promote postoperative comfort?

(50 words)

Question 17

Explain the rationale in taking routine observations on a patient that has returned from theatre.
Research and Reference

(20 words)

Question 20

Holistic approach to acute care is where all aspects of the person are considered.
What are 2 nursing interventions and outcomes Enrolled Nurses use to ensure a holistic approach to care.

Research and Reference

(50 words)

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