Pleuritic Chest Pain - Effect of Patho-physiological Change - Health Altercation Assessment Answer

Health Alterations Assessment Task 2 Case study

Step 1: Consider the case study below:

Mr. Smith is a 70yr/old male who presented to his GP at 10am today with an exacerbation of his CHF. He was complaining of chest pain that is pleuritic in nature, SOB, weakness, fatigue, a hacking cough with bilateral bibasal coarse crackles.

History:

Ax: penicillin

Meds: atorvastatin 20mg Mane, frusemide 20 mg mane, Metformin XR 1000mg BD

Past illnesses: hypercholesterolaemia, MI, angina, hypertension, Increased BMI 34, T2DM

Last meal: 7am (3hrs ago), bacon eggs, sausages toast and hash browns

Events leading up to presentation: walking/gardening on his farming property 3 hours away from the nearest hospital

His vital signs are a Temp 36.8, GCS 15, HR 105, NiBP- 170/90, Sp02- 92%, RR 24. Initial ECG displayed new abnormalities and initial bloods showed a negative troponin of TNI: 0.02. He was given his regular meds & 5mg IV morphine, 1gm paracetamol which reduced his pain to 2/10. PIVC insitu R) ACF- patent.

Step 2: Based on your assessment of the case study, identify 2 health care priorities for your patient. Refer to the ABCDE framework to justify your decision.

Step 3: Identify interventions (no more than 3 and at least one for each priority problem) to manage each priority. Provide a rationale for each intervention that refers to pathophysiology, as well as a discussion of related nursing care.

*Monitoring such as completing vital signs, telemetry and fluid balance charting is not an intervention. An intervention needs to effect a pathophysiological change. These may be nursing considerations

Step 4: Outline and Discuss appropriate discharge planning for this patient that aligns with the social justice framework

Considerations:

1. Make sure you draw on best available evidence to support your assessment. Journal articles must be no older than 5 years old. Textbooks no older than 7 years old may be used sparingly and only to support pathophysiological information.
2. Referencing correctly is an easy way to secure marks so put effort into this. Make sure you reference from credible journals that are related to the topic. For example; do not use references that are related to oxygen administration in children as this information is not transferable to this patient. It needs to be applicable to this patient.
3. Do not use google! Use the library databases.
4. Draft safe assign is set up for you to use so you can check your referencing in your assessment. Be sure to fix any issues before submitting your final assessment.
5. This is an academic essay written in academic language: use third person, do not use ‘I’
6. Make sure you use correct terminology within your assessment.

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