Tabitha is a 13-year-old girl who is enrolled in year
• Situation: • Henrietta is an 85-year-old female • She has had two hospital admissions in the past 12 months for management of exacerbation of her chronic heart failure • Henrietta has been brought into hospital by ambulance and you are caring for her in ED. She has presented with shortness of breath, fatigue and reduced exercise tolerance. • Background: • Henrietta lives alone in a rural coastal area • Past Medical History: heart failure, atrial fibrillation and hyperlipidemia. • Medications: 250 mcg daily digoxin, 20mg BD frusemide, 5mg BD ramipril and 2.5mg daily bisoprolol. Airway • Airway clear • Able to speak in sentences. • Orientated to time, place and person Breathing • RR 24 breaths per minute • SpO2 95% on room air • Bilateral chest expansion, no accessory muscle use • Auscultation – bilateral basal crackles evident Circulation • Heart rate – 80bpm • BP – 137/95mmHg • Skin: peripherally cool, capillary refill 3 secs • Colour: pale • Urine output – patient reports no changes • Weight: 70kg • Temp: 36.9 • Haematology results: WBC: 9.5 109/L, Hb: 12.4 g/L, Urea 10 mmol/L, Creatinine 110 micro mol/l, Na (sodium) 145 mmol/L, K (potassium) 4.7 mmol/L Disability • Alert (ACVPU – Alert, confused, voice, pain, unresponsive) • Blood glucose 4.9 mmol/L • No pain reported Exposure • Skin intact, no evidence of wounds • Temp: 36.9 • Pitting peripheral oedema present. Instructions • Discuss the pathophysiology of the presenting condition (giving consideration to the previous risks e.g. past medical history) • From the assessment information provided, explain the assessment findings • Conduct a body systems assessment (hint – reference the table from tutorials on secondary assessment/body systems assessment). • Using the assessment findings, discuss your nursing care (further investigations, nursing interventions, implementation and evaluation of care) Explain how you have addressed relevant NSQHS and NMBA standards (minimum expectation: one of each), and social justice principles
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