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1 page/β‰ˆ275 words
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Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
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Topic:

Identifying Clinical Assessment Data

Essay Instructions:

During my clinical day, i have 84 years old an American-Indian female patient. She was admitted yesterday for Acute Hypoximic Respiratory Failure and Generalized weakness. Patient medical history: COPD, UTI, and Pneumonia. Number 1 question I need to be trended are her previous vital signs: Temperature 101.2 it maight have fever; pulse 101.5 (Tachycardia); and respiration 22 is high. The current vital signs: BP 120/51, Temp 99.2, Pulse 100, Respiration 20, Oxygen saturation 98 and she in 3 liter canula. She is admitted to ER because of shortness of breath, she is two person assist. She is alert and oriented x4. She has several abnormal laboratory values including RBC is low 2,8; Hemoglobin is low 8.4; Hematocrit is low 25.6; carbon dioxide is high 37; BUN is high 27, albumim is low 2.8, BNP is 840, but not current laboratory result yet. Put number each question. Thanks
1. What clinical assessment data did you just collect that is RELEVANT today that needs to be TRENDED because it is clinically significant to detect a change in status? (state specific VS, lab values, and assessment data you collected and WHY relevant/ important)
2. What educational and discharge priorities have you identified and how will you address them this shift? Explain what teaching you provided and evaluate your patient's understanding of the teaching you provided.
3. What is the patient likely experiencing/feeling right now in this situation? (Caring/Psychosocial)
4. What can you do to engage yourself with this patient's experience, and show that they matter to you as a person?
5. Examine and discuss cultural/spiritual preferences and considerations for you patient.
6. Describe safety issues you identified when caring for your patient. How did you provide a safe environment for your patient?
7. Analyze abnormal and pertinent lab values and relate to your patient's condition/illness.

Essay Sample Content Preview:

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1. What clinical assessment data did you just collect that is RELEVANT today that needs to be TRENDED because it is clinically significant to detect a change in status? (state specific VS, lab values, and assessment data you collected and WHY relevant/ important)
Relative to the assessment that was conducted on the patient there are a set of data that was collected which can be considered for a trended review. Considering that the patient is at the age of 84, her pulse was too high while, her blood pressure measure is showing that she is suffering from low pressure or what is commonly referred to as hypotension. At the same time it is crucial to consider that her respiration was too high and when considering the amount of oxygen that she was getting in the body this was too low. As such this explains why she felt weak and her shortness in breath along with the low hemoglobin and high carbon dioxide.
2. What educational and discharge priorities have you identified and how will you address them this shift? Explain what teaching you provided and evaluate your patient’s understanding of the teaching you provided.
There are some important aspect to be considered when discharging the patient, one being that they understand the instructions given by the doctor and are ready to follow them strictly. The patient is also made to understand that they need ample rest and slowly increase the number of light duties they take part in and sitting down. It was also important that the patient understood that they should never drive while they feel that their blood pressure is low. It is also important for the patient to make sure that once they r...
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