Alex Simpson is a 40 year old male roof tiler who was admitted to the emergency department via ambulance following a high fall from the roof. He is complaining of pain in his abdomen, L) shoulder region and L) femur. He has just been admitted to your ward at 9am.
You have been asked to admit Alex, undertake a comprehensive physical assessment.
His past history includes; ( IDDM, HT, Obesity, Hyperlipidaemia, IHD, Angina, Ex-Smoker ) and he enjoys two cans of beer every day.
Using the system based assessment outline the following:
- 1. Your system assessment approach and the rationales supporting your assessment. Your rationales must be supported by evidence based current nursing literature.
- Priorities your system assessments approach with supporting rationales.
One hour at 10am following your initial assessment, you re-assessed Mr Simpson’s vital signs. You find he is distressed, and complaining of L) sided chest pain. He tells you `I feel terrible and I think I might be dying here`.
- Based on Mr Alex presentation please identify additional physical assessment required and why?
- 2. The rationales behind your examination. This must be supported by current and reliable nursing evidence based literature.
- Also outline at least 2 actual and 2 potential nursing complications relating to his current presentations at 10am and why?
For example: Washes hand prior to commencement of physical examination.
Rationale: Hand washing reduces the risk of infection transmission (Crisp and Taylor p.595).
Based on your findings, develop a comprehensive holistic nursing care plan for Mr Simpson. This nursing care plan should include the information gained in Part 1 the patient initial reason for admission to ED take into consideration his past history of your assessments. It must include 5 NANDA diagnoses (3 actual and 2 potential), with 3 interventions and rationales for each nursing diagnosis.