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10:44 ..11 4G < Back HNN227_Careplan_A... Q Case Scenario: You are a registered nurse working in the emergency department (ED) caring for Robertson, a 71yr old male who has just been brought in by ambulance (BIBA) found unconscious in his backyard by his wife. George has a past history of atrial fibrillation (AF), hypertension (HT), is a curre (15/day) and experienced a Transient Ischaemic Attack (TIA) 9 months ago with symptoms. George lives independently with his wife and his 2 adult children live suburbs. A falls risk assessment was completed on arrival and he has scored low his left hemiplegia and unable to move in bed. George has also sustained a deep his left check from the fall Mr. Robertson has presented with: Glascow Coma Scale = 11 (E2, V=2, M=5) Left-sided hemiplegia Dysphagia Aphasia His current vital signs are: BP 18791mmHg HR 87 bpm irregular RR 24bpm Temperature 36.8°C SpO2 94% RA Pain 8/10 (Wong-bak Assessment data Body Systems Assessment Neurological (CNS) GCS.IO Aphasic Dysphagia ΓΙΑ
10:45 ..11 4G < Back HNN227_Careplan_A... Q Body Systems Assessment Assessment data Neurological (CNS) GCS-11 Aphasic Dysphagia TIA Left-sided hemiplegia 36.8°C Pain 8/10 (Wong-baker) BP-187/91 mmHg HR-irregular Hypertension Atrial fibrillation RR-24bpm SpO2- 94%RA Smoker Cardiovascular (CVS) Respiratory Genitourinary/Renal Endocrine/Metabolic Gastrointestinal (GIT) Integument Musculoskeletal Psychosocial/other Married Lives with wife Independent with ADL's adult children Your Task: Drawing on the case scenario and the body system assessm nursing care plan for Mr Robertson by applying the nursin 1) Problem identification a. Identify four (4) actual and four (4) potent 2) Planning a. From your list of identified patient proble
< Back HNN227_Careplan_A... Q crointestinal (GIT) gument culoskeletal hosocial/other Married Lives with wife Independent with ADL's 2 adult children ask: g on the case scenario and the body system assessment data, develop a comprehens care plan for Mr Robertson by applying the nursing process: Problem identification a. Identify four (4) actual and four (4) potential patient problems. Planning a. From your list of identified patient problems select and prioritise the order two (2) actual and two (2) potential patient problems. b. Develop an appropriate plan of care for the two (2) actual and two (2) potential patient problems you have chosen. Implementation a. Identify two (2) priority nursing interventions for each of the two (2) actua and two (2) potential patient problems. b. Provide a rationale for each of the identified interventions explaining the underlining pathophysiology. Evaluation a. Explain how you will evaluate the effectiveness of each of the nursing interventions you have identified.