NURS1201 Adult Health Assessment

NURS1201:Adult Health Assessment

VitalSigns Graphic Charting Assignment

Part3:

1. What is the normal heart rate range for this patient?

120/80mmHgto 140/95mmHg

2. Do you notice any trends in his vital signs?

a.HR:the heart rate of Bert Jones kept increasing throughout the day.However on 01stof March, there was a usual rise with the first three heart ratereadings and a drop in the fourth reading. On 2ndof March, there was the usual rise for the first two readings and adrop with the last reading.

b.SpO2:the first reading recorded for the day was high and the levels ofsaturation kept on reducing as the day went by.

c.Temperature:for everyday that temperature was taken for Bert Jones, after thefirst reading of the day, the temperature levels kept rising.

d.Respiration Rate:this reading kept on fluctuating depending on the temperature readingrecorded. When there was a rise in the temperature noted, there wasalso a rise in the respiratory rate. Also the early morning readingis relatively low as compared to the subsequent readings of the day.

e.Blood Pressure:after the first reading of the day, the second reading was higher andthe subsequent reading lower.

3.

a. Most-02ndMarch at 1215hrs. The patient recorded high vitals, that is, oraltemperature of 380C,respiratory rate of 22 breaths per minute and heart rate of 100breaths per minute. At the same time, the patient was on oxygen vianasal prongs to achieve normal saturation of 98%. The systolic bloodpressure was low at 115 while the diastolic was a bit elevated at 90.

b. 2nd-02ndMarch at 0910hrs. The patient had a relatively high blood pressure of140/95mmHg, a radial pulse of 165 beats per minute and an apicalpulse of 110 and oral temperature of 37.80C.at this time Bert Jones was saturating at 92%.

c. 3rd– 02ndMarch at 0320hrs. Bert Jones had an elevated blood pressure of140/92mmHg, oral temperature of 37.40C.At the same time radial pulse was 100 beats per minute.

4. Why would the SPN measure an Apical Rate on March 2nd?

TheSPN measured the apical pulse to get further assessment data thatwould be a baseline for intervention.

5. Can you provide your opinion for the temperature changes on 2015 Mar02:

Hyperosmotichyperosmolar nonketotic syndrome resulting in very high blood glucosethus elevated temperature. The patient could be harbouring a systemicinfection which caused an elevation in his body temperature.

b.What are 3 nursing (non-Pharmacological) interventions that couldhave helped the temperature?

Regulatethe room temperature, which is, opening the windows of the room andturning off any heaters.

Reducethe quantity of linen covering the client as well as the amount ofclothing the client is wearing.

Performtepid sponging for Bert Jones using warm water and a towel.

6. using the information from the vital signs can you:

a.List and prioritize 3 assessments (not Vital Signs) you wouldundertake to gather moreinformation?

Randomblood sugar level- Bert Jones is a diabetic client. Thus assessingthe blood sugar levels will help to determine whether the client isgoing into hyperosmolar hyperglycemic nonketotic syndrome (HHNS)which is the extreme state of type two diabetes.

Collectblood samples for white blood cell count. This will enable us to knowwhether Bert Jones has a systemic infection that could be causing theelevation in temperatures.

Collecturine samples to check for presence of any pus cells that couldsuggest urinary tract infection.

b.Make an educated guess as to the results you would find on theassessments you choose to do?

Extremelyhigh blood glucose

Anelevated white blood cell count

Presenceof pus cells in urine

c.Make an educated guess as to the 3 most likely explanations for thevital sign changes you are noticing?

BertJones could be having very high blood glucose which is the cause forelevated temperatures.

BertJones also has signs of dehydration. This could be the reason as towhy he had a very low blood pressure on 02ndMarch at 1215hrs.

BertJones could be harbouring an infection which is the reason as to whytemperature levels are elevated.

Atthe same time Bert Jones could be experiencing emotional instability.As seen in the history his wife passed away last year and hischildren live outside the province.

d.Anticipate 3 care measures for the patient in response to what ishappening in this case?

Hydratethe client but with precaution to avoid fluid overload which couldotherwise result in very high blood pressure.

Makea fluid chart for the patient to enable us to monitor input andoutput and detect fluid overload or deficit.

Thepatient will probably be prescribed for antibiotics in case there arepus cells in urine or an elevated white blood cell count. This mustbe administered as prescribed to avoid antibiotic resistance.

Counsellingand occupational therapy for the patient to promote emotionalstability.

7.What is the SBAR you would give your Instructor when they speak withyou Mar 02 1600?

S:Bert Jones is an 87 year old male who is currently living in anassisted care facility. He has diabetes mellitus type 2 andhypertension. Bert Jones is complaining of being weak and tired. Heis on oxygen via nasal canula. From 1215hrs, his vital signs havebeen quite abnormal.

B:Theclient complains to have lost four pounds of weight over the past forweeks and reports to also be having poor appetite. The patient isalert and orientated to person, place and time, but is forgetful withpoor short-term memory. He is complaining of feeling “weak andtired” and of being dizzy when standing up with a “flutteryfeeling” in his chest. His skin is pale, warm and dry with poorturgor. His oral mucous membranes are dry and intact, with dry lips.His abdomen is soft and flat with hypoactive bowel sounds. Hiscurrent medications include those for his diabetes and hypertension,as well as a multivitamin. His wife passed away last year and has twochildren and five grand children living outside the province.

A:Today at 1545hrs, Bert Jones recorded a very high temperature of 380C, this is the highest temperature reading ever recorded for him sinceadmission. He also recorded a blood pressure of 130/74 while sittingand a relatively high radial pulse of 142beats per minute. Thepatient is saturating at 95% on 2liters per minute of oxygen vianasal prongs and has a respiratory rate of 20breaths per minute.

R:At this time, the quantity of linen used to cover the client has beenreduced. Also, the amount of clothing he was wearing has been reducedtoo. Room temperature has also been regulated by opening the windowsand the door partially. In my opinion, the patient may be havinghyperosmoler hyperglycaemic nonketotic syndrome, thus the bloodsugars should be able to provide a baseline for necessaryintervention. Also, it could be an underlying systemic infection.Samples of blood and urine can be collected to rule out this.