Complex Adult Health Needs 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

Diagnostic Tests

Medications

Nursing Diagnoses

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.

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 evidence‐basedliteraturesourcestosupportyourrecommendations. 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.

Conclusion

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