Assessment Notes: Written assignment – Situational Case Study
No. Words: 2000
Task
- Select a case from the options below
- You are the registered nurse working in the medical ward and are preparing selected cases for discharge from the hospital into the care of a chronic care nurse manager working in primary health care (including home care). Discuss the following to demonstrate your understanding of selected case’s ongoing care.
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- Identify all data that is relevant to complete a comprehensive nursing assessment for the selected chronic condition/s and prioritize current care needs specific to his/her presentation as part of the nursing assessment.
- Identify all contributing factors for selected case’s chronic conditions and current health exacerbation.
- Identify all nursing assessments, interventions and strategies for the selected case to effectively manage the chronic condition using a self-management approach.
- Discuss the literature on the nurse’s role in chronic disease self-management.
- Discuss primary and secondary health promotion and education strategies appropriate to the selected case.
- Proper APA7th Referencing style
Case Study 1
Clare Giardini is a 70-year old women, who frequently presents to both her local General practitioner and also the local emergency department. In the last three months she has presented to the local hospital with shortness of breath six times. On occasion she misses her local GP appointments and runs out of her medications whilst waiting for her pension.
Social History
She lives happily on her own and has two adult children who live several hours away. Clare’s husband passed away over five years ago from complication of his diabetes and cardiac disease and she cared for him during his last few years. Clare lives in town in government housing and she enjoys knitting and playing with her pet cats. Clare grew up in her local town and has never left in her 70-years she has many friends that she meets at the local club for lunch twice a week.
Medical History
Clare has a history of osteoarthritis, non-insulin dependent diabetes and hypertension. A recent echocardiogram showed systolic dysfunction and a poor left ventricular ejection fraction, and she is noted to have chronic controlled atrial fibrillation.
Medications
- Metformin
- Paracetamol
- Diclofenac
- Quinapril
- Furosemide
Objective data
- Temperature 36.8
- Radial pulse 91 beats per minute and irregular
- BP 112/65 mmHg
- Cardiac system S1and S2, present, no murmurs
- Respiration rate: 22 breaths per minute and shallow, SpO2 94%
- Lung sounds: crackles in both bases
- BGL: 8 mmol/L
- HbA1C: 75mmol/mol
Subjective data
- Pain is 2/10
- Fatigue
- Orthopnea
- Nocturia up to six times per night
