Assess Clients & Manage Client Care
Case Study Ms Aliza Azizi
Ms Aliza Azizi is a 44 year old female lawyer and a practising Muslim. She was admitted to the respiratory ward with L) LL Pneumonia, with a productive cough and fever. She returned from oversea holiday 2 days ago, patient stated that she had upset stomach and diarrhoea whilst she was on holidays.
Her PHx includes: Asthma, UTI, IDDM, HT and DVT (2016).
She is currently on medications: Seretide MDI (250/25) 2 puffs – mane; Salbutamol MDI 2 puffs – QID as well as PRN; Warfarin 5mg -daily; Perindopril 2.5mg Daily; Novomix 30/70 10units S/C – mane & Actrapid 4units tds with meals and Doxycycline 50mg- bd.
You have been asked to admit Ms Azizi, including a comprehensive physical assessment.
Her initial vital signs in ED were: RR 28, O2 Sats 94% on RA, BP 140/90, HR 110, Temp 37.9c & pain score of 2/10 RIB.
She is currently complaining of feeling nauseated, stomach cramps and having loose bowels overnight. She is also slightly short of breath while speaking to you.
PART 1: Nursing Assessment
Using the System based assessment outline the following:
1. Prioritise the nursing assessment from most urgent to least urgent, using the system assessments (i.e, CNS, CVS, Resp etc…). Each assessment must be supported with rationales clearly stating why you are conducting the assessment for the patient relating back to the patient’s condition. The rationale also need to be support by a reference (evidence based practice) published within the last 5 years.
Respiratory Assessment: The respiratory assessment concentrating on respiratory rate and chest auscultation would be required for this patient as currently patient is cool to touch and the patient’s lip turning blue. Gulanick & Myers (2014, pg. 201) states that “Cool, pale skin maybe a secondary to a compensatory vasoconstriction response to hypoxemia. As oxygenation and perfusion becomes impaired peripheral tissues become cyanotic”.
Then explain why you are concentrating on respiratory rate and chest auscultation. By conducting these assessments what can you confirm or eliminate maybe the cause of patient’s signs and symptoms.
PART 2: Nursing Complications/Problems
2. Clearly outline at least 4 actual problems & 2 potential problems relating to the patient’s current signs and symptoms & patient’s past history.
PART 3: Nursing Implementation and Evaluation
3. (A) Based on your assessment findings from Part 1: Nursing assessment, develop a Holistic nursing care plan for Ms Azizi including;
• You must use the “Example of a Care plan template” provided.
• 2 Nursing Interventions- for each nursing complications (4 actual and 2 potential, thus 12 nursing interventions in total).
• Rationale- Each intervention should be supported with a rationale/s (referenced no older than 2012).
• Nursing Evaluation /outcome- for each nursing interventions implemented please state your evaluation or expect outcome for each of the interventions.
(B) State at least 3 nursing educations with clear rationale/s that you will need to provide Ms Azizi before her discharge directly relating to her reasons for admission or Ms Azizi’s potential problems.
Nursing complications (Actual & Potential Problems) Interventions Rationale Evaluation
1) Patient unable to do ADLs independently as patient has a # NOF and asked for assistance with ADLs.
1. Offering analgesia prior to care as ordered by the doctors.
2. Encourage patient to set own pace during self- care.
1. Analgesia decreases the pain level allowing patient to carry out some ADLs(Reference as per Harvard guidelines and BHI student handbook – e.g.(William & Hopper, 2014)
2. By allowing patient to do small amounts of self- care increases their self –esteem. ( Kelly and Jones 2016)
Patient was able to perform ADLs within a week.