Medical Case Study
Florence (F) is a 43-year-old woman who is two days post-operative, following an appendectomy. She has a history of arthritis, and currently takes 10mg of prednisone daily. She is allergic to penicillin. She weighs 46 kg (101.5 lbs.) and is 168cm tall (5'6"). This puts her slightly underweight for her age and height, at least 18-25 pounds (Height and Weight Chart, 2010). While doing a route in dressing change, nurse notice a yellow discharge emanating from the wound.
Identify and discuss the importance of obtaining information during a nursing admission in relation to post- operative assessment. In modern healthcare, a nurse must first and foremost try to understand and utilize a systematic and synergistic model of data collection and assessment. Human beings are complex creatures, and the more data one has, the easier it will be to ensure that a proper diagnosis is made. A systematic assessment provides a framework which ensures that data gathering will be consistent; it individualizes nursing care, and maximizes the amount and quality of information that a nurse can obtain from a client within a short time. This is done by also understanding the differences between objective and subjective data. Subjective data, for instance, consists of the history obtained from the patient through an interview -- the chief complaint, history of family illness, psycho-social history, normal daily activities and a complete overview of the major bodily systems. The data is subjective because it comes from the patient who may, or may not, be able to accurately identify issues from an objective viewpoint. This is the most important part of the data base about a patient -- for research shows that over 80% of all diagnoses may be accurately made by obtaining a complete and robust history. Once this data is collected, the patient's symptoms are cataloged and objective (e.g. medical measurements and tests are performed to confirm the patient's complaints) (Viljoen, 2007).
Q2. Identify and discuss the nurse's role in consent procedures for patients undergoing a procedure involving general anesthesia. Most medical institutions require a patient or their legal guardian signing a general consent form upon admission. This authorizes general treatment that the physician deems necessary. Different states, however, require informed consent forms to be signed based on different procedures and different risk factors. Without these informed consent forms, the hospital and attending physician are actually at risk. Actually, informed consent is a process, not just a few pieces of paper. Because general anesthesia carries risks, it usually falls to the nurse to inform the patient that there might be a potential for unfavorable reactions to any medication or anesthetic agent that may be given during any surgical procedure. The nurse is usually more communicative in detailing the risks without causing the patient undue worry or stress. Plus, if the surgeon needs to perform a procedure not specifically specified on the consent form, the nurse also has the responsibility to inform all stakeholders (including the doctor and/or surgeon) that there is a discrepancy. Prior consent is necessary to protect all sides, since there are risks in any procedure. The nurse, acting as the patient advocate, is best equipped to give the right amount of medical information in a way that makes sense to the patient and their family (Phillips, et.al., 2007).
Q3. Identify and discuss the purpose of vital sign data in the pre and post-operative period. - Identifying health problems is the second phase in evaluating person centered care. By critically examining the initial interview the nurse can find information on the person's health resources (strengths and weaknesses), risk factors, current health problems, potential problems and complications. In addition, a collaborative means of identifying actual and potential health problems is easiest done by answering at least most of the following questions: What did the person say in their interview? What did the family or significant other say? What did you observe about the client? What did you find while performing a physical examination? What did you read in the previous medical history? What was said in team meetings/handovers, or gleaned from other colleagues? In this manner, the assessment is more accurate because there are numerous points-of-view used to establish a better health picture of the individual (Potter and Perry, 2007).
Q4. Define and identify the purpose of wound assessment -- Wounds are disruptions of normal anatomical structures and function. Wound assessment is the technique necessary to provide care plans, treatment, and ongoing medical management for that patient. Accurate wound assessment is not simply reviewing the wound, but assessing the total patient -- comorbid conditions, lifestyle, and events that may have contributed to the wound. One way to think of wound assessment...
In 1858, Louis Pasteur identified germs, proving that diseases did not 'spontaneously' arise as nightingale thought (Atwell, 1998). However, it was Nightingale that began work as to the conditions that promoted the growth of germs, but she would not know this for many years. The Crimean War: Putting Theory Into Practice When the Crimean War broke out, she began work at once in a British hospital. Her emphasis was placed on
Supreme Court cases (Muller V. Oregon) women's right Why it was an issue of national importance The Muller v. Oregon case was among the most crucial Supreme Court cases in the U.S. during the progressive regime. The case held an Oregon law that limited the working days for female wage employees to a maximum of ten hours. In 1908, this case created a precedent to expand access of national activities into the
The death of a child is significant and in this case avoidable and a plaintiff has the right to seek compensatory damages as is allowed by law. Case Study 1 Part B At the end of the night shift, Nurse Brown took a verbal handover and then noticed the observation chart had not been filled in. To assist her friend, Nurse Harvey, whom she knew had a busy night, filled in the
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Sleep deprivation is frequently a direct result of the need for intensive care, constant surveillance and monitoring that combine to limit the opportunities for uninterrupted sleep in the intensive care unit (ICU). The problem is multifactorial, with patients' chronic underlying illness, pain, pharmacological interventions used for the treatment of the primary illness, as well as the ICU environment itself have all been shown to be contributing factors to the process
, 2010). It is perfectly conceivable that this nurse leader would welcome more collaborative or shared leadership responsibilities, particularly since the setting for empirical clinical research on this very issue was, in fact, an ICU (Rosengren, Bondas, Nordholm, et al., 2010). Finally, it appears from this interview subject's input into this project that she is a competent and effective nursing leader, largely by virtue of her description of her supervisory and
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