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Complex Adult Health Needs Assessment

Info: 2947 words (12 pages) Nursing Assignment
Published: 3rd Jun 2020

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Tagged: assessment

Background Information

Patient J. H.  is an 84-year-old African American female. Past medical history includes upper gastrointestinal bleeding, hyperlipidemia, Cerebral Vascular Accident in the cerebellum since 06/15/2017, hypertension and arthritis. Surgical history includes a hysterectomy and laser cataract surgery. Patient’s diagnoses are meningitis and hypertension.

Patient was presented to the emergency department with complaints of altered mental status for 24 hours, a blood pressure of 204/140 and a fever of 101.1 Fahrenheit. Patient’s daughter brought her to the ED and stated that patient was found to be incoherent when daughter came back home from grocery shopping. Upon assessment, neurological status was evaluated. Patient was alert and oriented only to self. Patient could not state where she was, what time it was and the reason for being hospitalized. Pupils were round and reactive to light and brisk bilaterally. Face is symmetrical. Reflexes were two plus. Patient’s speech was inherent and was not able to follow to follow commands. Vital signs were heart rate of 64, blood pressure of 177/91, respiratory rate of 18, temperature of 97.9 and oxygen saturation of 97%. Head is normocephalic with no lesions and no masses. Eyes are symmetrical with conjunctiva pink and sclera white. Ears are symmetrical with no drainage and no pain when palpating tragus. Nose is symmetrical with no drainage and no deviated septum. Trachea is midline. Mouth is symmetrical with dry mucous membrane and tongue midline. Upon auscultation, lung sounds were clear bilaterally with no adventitious sounds. No accessory muscle. Respiratory effort normal. S1 and S2 were heard with no extra sounds and with regular rhythm. No elevation of jugular vein was observed. Bowel sounds were active on all four quadrants. Abdomen was nondistended and nontender.  Pedal pulses and tibial pulses plus two. No edema on lower extremities. Extremities were warm and dry upon palpation. Skin was dry and no intact with no lesions or rashes.

Labs and Diagnostic Tests

WBC 15,000 Patient presented to ED with fever of 101.1 and admitting diagnosis of meningitis
Hgb 13.7 Within normal range. Patient had a history for upper GI bleed.
Htc 42.6 Within normal levels.
Platelet 315,000,000 Within normal levels. Patient received antiplatelet and anticoagulant therapy for deep vein thrombosis prophylaxis and stroke prevention.
Neutrophils 13.7 Patient’s neutrophil count is high due to meningitis infection.
INR 1.2 Within normal. Patient is on anticoagulant and antiplatelet aggregator therapy to prevent deep vein thrombosis and stroke.
BUN 21 Slightly elevated probably d/t acute kidney injury
Creatinine 1.1 Within normal levels. Patient in on several antibiotics and has a history of acute kidney injury.
Sodium 135 Within normal levels. Patient received a complete metabolic panel.
Chloride 98 Within normal levels.
CO2 35 Within normal levels
Alk Phos. 148 Slightly elevated. Can be correlated due to infection.
Proteinuria 500


Diagnostic Tests

Test Reason (s) Needed
EKG To monitor for nay cardiac changes
CT To rule out Cerebral Vascular Accident. Results showed diffuse atrophy and moderate chronic changes. Patchy low-density area noted in left posterior parietal lobe.



Trade Name, generic name & classification Pharmacological & Therapeutic use Adverse Effects Time, dose & route Why is patient receiving this medication Nursing Implications
Acyclovir (ZOVIRAX)

Antiviral & purine analogus

Medication interferes with DNA synthesis.  It stops viral replication. Seizures, dizziness, N/V, headache, renal failure, Steven-Johnson Syndrome Dose: 455 mg in 250 mL sodium Chloride 0.9%

Time: 0500, 1700

Route: IV

Patient was admitted with diagnosis of meningitis. Started pt on this medication since at this time it wasn’t known if it was bacterial or viral. Monitor BUN, Creatinine before and after medication administration. This medication can lead to kidney failure.

Anti-infective propreties and aminopenicillin 

Binds to bacterial cell wall leading to cell death. It is used as a bactericidal for infections caused by Streptococci, Pneumococci Seizures, C. Diff, diarrhea, rash, anaphylaxis, serum sickness and superinfection Dose: 2 g in sodium chloride 0.9% in 100 mL

Time: 4 times per day

Route: IVPB

During the period of care, patient had meningitis. Patient was receiving IV antibiotics Assess for s/s of infection. Assess patient for s/s of anaphylactic shock. Assess bowel function. Monitor liver enzymes


3rd generation cephalosporin

Binds to cell wall membrane & cause cell death. Seizures, C. Diff. D/N/V, cholelithiasis, pancreatitis, agranulocytosis, hematuria, phlebitis at IV site. Dose: 2g in 50 mL sodium chloride 0.9%

Time: q 12hr

Route: IVPB

Patient is receiving this antibiotic to treat meningitis. Assess of s/s of infection. Assess bowel function as it can lead to C. Diff. Assess for rash during therapy. Monitor Liver enzymes, BUN and creatinine
Clopidogrel (PLAVIX)

Antiplatelet agent

Platelet aggregator


Inhibits platelet aggregator. Reduces the risk for developing a stroke or Myocardial Infarction Epistaxis, GI bleeding, neutropenia, abdominal pain, edema, hypertension, gastritis Dose: 75 mg

Times: daily

Route: PO

Patient is receiving this medication to prevent development of stroke. Patient has a developing stroke Assess pt for signs of stroke. Monitor for s/s of bleeding. Monitor platelets
Enoxaparin (LOVENOX)



Prevents formation of thrombus Bleeding, anemia, dizziness, constipation, urinary retention, rash, ecchymoses Dose: 30 mg/0.3 mL

Time: Daily

Route: SC

This is a prophylactic treatment to prevent deep vein thrombosis Assess for s/s of bleeding or hemorrhage

Observe site of injection for hematoma or inflammation

Monitor of hypersensitivity.

Monitor CBC and platelets

Famotidine (PEPCID)

Antiulcer agent

Histamine H2 antagonist

Prevention of gastric ulcers by inhibiting secretion of gastric acid Confusion, drowsiness, hallucinations, arrhythmias, agranulocytosis, drug-induced-hepatitis Dose: 20 mg diluted in 5 mL 0.9% NS.

Time: daily

Route: IV

Patient on gastrointestinal bleed prophylaxis. Assess abdomen for any epigastric pain. Assess for frank or occult blood. Assess elderly for confusion
Hydralazine (APRESOLINE)



Causes peripheral arteriolar vasodilator. Lowers blood pressure Dizziness, tachycardia, angina, arrhythmias, orthostatic hypotension, drug-induced lupus syndrome Dose: 5 mg

Time: PRN systolic greater than 160.

Route: IV

Patient has a history of hypertension. Patient has been hypertensive throughout hospitalization. Monitor and assess blood pressure and heart rate during therapy.

Nursing Diagnoses

Nursing diagnosis Nursing outcomes Nursing intervention Collaborative interventions
Decreased cardiac output related to heart not being able to meet metabolic demands as evidenced by patient’s blood pressure being >177/>140. Stabilize blood pressure to normal base <177/<140




Administer hydralazine per MD orders. Monitor blood pressure q 30 min.

Raise HOB and stay with patient to provide support


Disturbed thought process related to cerebral infection as evidenced by patient grabbed my hand upon assessment and pretended it was a phone Patient will demonstrate regain of consciousness by end of clinical day



Risk for injury related to altered level of consciousness as evidenced by patient is restless and tried to get out of bed several times Patient will remain free of injury throughout clinical hours.

Patient will recall her name and current date.

Patient will not be restless by end of clinical day


Prevent injury by raising 2/4 bedrails and staying with patient.

Orient patient to person, time and situation.

Decrease stimuli by turning off lights and maintaining quiet environment



Nursing Interventions

Different interventions were provided for the patient to provide an overall quality of care.  Patient’s level of consciousness was impaired which prevented patient from moving and repositioning. To prevent skin breakdown and the development of pressure ulcers, patient was repositioned every two hours. According to a scholarly article, repositioning every two hours helps relieve pressure and friction off certain skin areas which can potentially lead to the development of skin breakdown (Peterson, M. J., Gravenstein, N., Schwab, W. K., van Oostrom, J. H., & Caruso, L. J. 2013). The patient was not able to independently move due to weakness and altered mental status from meningitis diagnosis.


Describe 3-5 independent nursing care you provided in the care of the critically‐ill individual. Examples include, but are not limited to: activity level, position, ongoing monitoring, and nutrition (prescribed diet, tube feedings/TPN, formula, rate, patient education, & wound care etc.). Each intervention should include a rationale, evidence to support the intervention with citation, and why it is important to the client. Each intervention should be a paragraph. One way to set this up is MEAL. M=main idea (ie positioning), E=evidence (citation of scholarly article supporting this intervention. For example. According to Perry and Potter (2016), repositioning should be done every two hours to avoid impaired skin integrity.), A= analysis and               L=link to patient (This client was immobile due to a fracture of the right femur and will need assistance with repositioning to avoid skin breakdown.


Interdisciplinary Management

Collaborative Care Management

To be able to provide overall care of the patient, interdisciplinary care must be provided.

Patient was diagnosed with meningitis. A sample of cerebral spinal fluid was needed to confirm the patient’s diagnosis and to select the correct antibiotic treatment to eliminate infection. Unfortunately, patient’s power of attorney declined spinal fluid tap. Collaboration with physician and neurologist was needed to intervene and to provide teaching on the benefits of such procedure.

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The neurologist is a type of physician that specialized in diseases of the brain and spinal cold. The role of the neurologist is to provide and explain the benefits of a lumbar puncture to the patient’s durable power of attorney. The patient’s power of attorney was concerned about the lumbar puncture and the risks associated with it. The neurologist’s role was to provide patient and family education on the benefits and complications of this procedure. Patient’s power of attorney ended up declining procedure.

Since patient has a history of an evolving stroke and has lost strength and mobility of the right arm, occupational therapy was another interdisciplinary collaboration requested for the patient. Occupational therapy (OT) role is to help patient retain or regain the abilities lost prior to stroke. OT helps to gain or maintain the ability to perform activities of daily living (ADLs) such as regaining the ability to move arm completely or partially, learning how to cook, bathe, or brush teeth (The Role of Occupational Therapy in Stroke Rehabilitation (n.d). OT provided the patient of passive range of motion exercises. The overall goal of OT is to help with stroke recovery.

Therapeutic Modalities

Describe the various therapeutic modalities used in the management of care for the critically‐ill individual. Discuss the extent of the nurse’s responsibilities and skills required to manage the therapeutic modality in comparison to the responsibilities of the members of the interdisciplinary team. Therapeutic modalities include but are not limited to oxygen therapy (mode, FiO2,), dialysis/CRRT (settings), ventilator therapy (mode of ventilation, settings, FiO2). The rationale must be included for each modality. Each therapeutic modality should be a paragraph and have an in-text citation and reference.

Nursing Role Reflection

Provide a brief summary of how your role interacted with the members of the interdisciplinary team. Each section should be a paragraph and include:

•                      Analysis of communication style preferences among interdisciplinary team members and with the critically‐ill individual and family members. What is the impact of your own communication style on others?

•                      System barriers and facilitators. Did the organizational framework for interdisciplinary management of care facilitate or hindered the quality of care/outcomes for the critically‐ill individual? What evidence-based recommendations can you make to the organizational system for enhancing interdisciplinary collaboration? Provide at evidencebasedliteraturesourcestosupportyourrecommendations. Examples include SBAR, bedside rounding, etc.

Professional Development. Based on your experience(s), write ideas for your own professional self‐development plan to enhance your potential for becoming an effective member in an interdisciplinary team. For example: seminars, webinars, classes, CEU’s, etc.


Papers should end with a conclusion or summary. The assignment directions will specify which is required. It should be concise and contain little or no detail. No matter how much space remains on the page, the references always start on a separate page (insert a page break after the conclusion so that the references will start on a new page).

  • The Role of Occupational Therapy in Stroke Rehabilitation (n.d). Retrieved from https://www.aota.org/About-Occupational-Therapy/Professionals/RDP/stroke.aspx
  • Peterson, M. J., Gravenstein, N., Schwab, W. K., van Oostrom, J. H., & Caruso, L. J. (2013). Patient repositioning and pressure ulcer risk-Monitoring interface pressures of at-risk patients. Journal of Rehabilitation Research & Development, 50(4), 477–488. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1682/JRRD.2012.03.0040


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Specific health assessment refers to an assessment of a specific problem and it may be the initial assessment or an ongoing assessment. A specific assessment is problem oriented, it focuses on a specific problem and not a general health.

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