Health Issue - Health Promotion Strategies - Diagnoses - Nursing Assessment Answer

Health Issue - Health Promotion Strategies - Diagnoses - Nursing Assessment Answer

Task:

This assessment requires students to make an oral presentation that demonstrates knowledge of and ability to apply the Clinical Reasoning Cycle (CRC) to plan nursing care of the older adult.

This assessment requires you to:
 Plan the nursing care of an older adult using steps 5, 6, 7 and 8 of the Clinical Reasoning Cycle (CRC) (Levett-Jones, 2018).
 Base your plan of care on the first 4 steps of the CRC which are provided as part of a detailed case scenario.
 In Step 4 of the CRC the client health issues have been identified and the task is to select one of these health issues and create a detailed plan of care to address the selected health issue, with an emphasis on health promotion strategies to enhance the client’s quality of life.

Objective:

•  On observation, pt looked pale and unwell
•  Low BP (95/50)
•  Rapid shallow respirations - 28 per min
•  HR 88 bpm
•  Temp 37 degrees C
•  Oxygen saturation 95% RA
•  Weight 44kg
•  Height approx. 160cm 
•  A large but shallow skin tear on her right lower leg
•  Swelling in her lower limbs - bilateral

b) Discriminate - between what is relevant to the client’s condition or treatment and what is not, and what is important and what is less important to the client’s condition or treatment at this time.
Most important:

•  Vital signs – esp. low BP given she is on antihypertensive medication
•  Pain
•  Lumbar fracture
•  Mental health
•  Activity limitation
•  Leg wound
•  Cough
•  Low body weight

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