Further Questions for the Nurse During Handover:
I would ask the nurse some questions for clarity; What were the differential diagnoses and how were they eliminated to conclude it could be pneumonia specifically? This gives me the reason to rule out pulmonary tuberculosis because I suspect it could be there (Williams, 2016). Again, I would ask the changes that are expected on the patient for me to be ready. What are the latest vital observations of temperature, pulse, respiration rate and blood pressure? Are any family members present and who was the secondary source of information during the primary assessment? Is the patient on any other drugs from the previous conditions? Were there any dietary alterations in the past week that may have led to weight loss? Does the patient have any cognitive impairments and psychological instabilities? Does the patient have any drug or food allergies? What are his commonest stressors? What are the values and beliefs that he holds dear? What is the patient’s perception of his condition? If answered, I shall have a broader scope of patient information for continuity of care (Williams, 2016).
Further assessments: I would do a further respiratory assessment to rule out PTB. This is to be done by auscultation anteriorly and posteriorly where there could be unilateral air entry and the other one is not. Also, I will do a cardiovascular assessment to confirm if congestive cardiac failure (CCF) is contained. Stool assessment for any occult blood would help confirm the resurgence of gastric ulcers or if the abdominal pain was just due to another GIT infection. Examining the stool for occult blood is done by collecting some of the stool and seeing if there are patches of blood that is digested. I will take vital signs hourly to detect any changes. I will assess any evidence of cardiac overload during the administration of normal saline considering that he has a history of CCF and he is old. This is done by assessing the extremities for pitting edema and orbital edema as well. I would also do an assessment based on the eleven functional health patterns by Gordon (Levett-Jones, 2013). This will help capture other details that may contribute to his recuperation (Williams, 2016). The assessment that I would do after receiving the patient involves the blood pressure, temperature, pulse and respiratory rate (vital signs). This helps in management of any emergencies that could occur. Again, a nutritional assessment by taking the Body Mass Index (BMI) would help in adjusting the client’s IV supplements since he has abdominal discomfort that may be due to the gastric ulcers. This is done by taking the weight in kilograms over the square of his height in meters. The weight loss could be as a result of malabsorption. Also, pain scaling would be important where I would rate it as severe, moderate or mild.
Consider the patient situation
· What current information do you have on this pt?
· What new information have you gathered?
Mr. Joe, is a 92-year-old male with a history of gastric ulcer, CCF and CVA. He has a chesty cough and is producing sputum. He lost 3 kilograms of weight in the previous week.
Currently, he is on 1.5 liters of oxygen through a nasal prone. The left hand has an IV cannula and he has received antibiotics; IV gentamycin and cephazolin as indicated in the treatment chart. He takes nothing per oral and has passed stool twice and the urine output is consistent.
· What further cues and information would be useful? Why?
The weight loss of 3kilograms could be as a result of malabsorption and so I have to ask him whether he felt some abdominal pain after meals and could that be the reason he did not eat. This helps note the cause of the weight loss. (Felton, 2012)
· What changes do you notice in the cues and information provided?
· Which changes are significant for this patient and why?
· What do you think these changes could indicate and why?
· What could be the outcome of these changes?
The changes that are notable in the cues are the onset of abdominal pain and chesty cough. The need to rule out other respiratory pathologies like PTB is important. If the chesty cough has taken more than two weeks, then we could suspect PTB and the sputum test could be confirmatory.
The outcome of these changes could be a change of treatment to the anti-TB drugs and shifting the patient to a secluded TB unit.
(Lee, Lee, Bae, & Seo, 2016)
· Given the facts that you have available and comparing those to what you think the changes could indicate/identify one potential patient problem/issue.
Upon reviewing the history and the changes that I have noted, one potential patient problem is nutritional imbalance related to malabsorption secondary to gastric ulcers.
· Describe what you want to happen.
· Who do you want involved and what do you want them to do?
· In what timeframe?
The most important intervention for the patient after pain management is nutritional review and subsequent supplementation. I would review the patient with the help of a nutritionist so that the best intervention is made. This is important to boost his immunity. After a span of four days in the ward with IV nutritional supplementation, the client is expected to gain weight.
· What nursing actions will you take?
· What will be your nursing priorities?
Patient teaching on coughing techniques and hygienic interventions. Also, I would initiate a psychological support program.
Administration of prescribed antibiotics and other medications that could be helpful.
My priority shall be the administration of analgesics and nutritional supplements.
· What do you expect to achieve from the actions have taken?
I expect that the patient will verbalize absence of pain 20 minutes after administration of analgesics. Also, the patient will gain weight after four to five days of nutritional supplementation. (Levett-Jones, 2013)
Reflect on Process and new learning
· What have you learnt from this exercise?
I have learnt that cues are important because they give specific health information that may help change the patient’s condition and they are elicited through the clinical reasoning process.
Felton, M. (2012). Recognising signs and symptoms of patient deterioration. Emergency Nurse, 20(8), 23-27.
Lee, J., Lee, Y., Bae, J., & Seo, M. (2016). Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. Nurse Education Today, 46, 75-80.
Levett-Jones, T. (2013). Clinical reasoning. Frenchs Forest, N.S.W.: Pearson Australia.
Williams, R. (2016). Handover standards. Nursing Management, 23(2), 19-19.