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Table of contents

Part 1.

Analysing the cues.

Information collected from the case study.

Part 2.

Nursing problem..

Part 3.

The reflection.

References.

Clinical Care - Part 1

Analyzing the Cues

In the given case study, it was identified that the General practice diseases have been identified. In addition, General practice refers to every kind of common disease and the care provider may have the right to refer the person who needs care to any Medicare place. From the following case study, we have found that the care person has presented a few general diseases such as vomiting, headache, nausea and dizziness. However, the person from the care person side has confirmed that the person has not any previous medical issue as well as the person seems to be physically fit as well as healthy.

The care provider has prescribed metoclopramide after the checking of that care person. In addition, this specific medicine has been used for the development of muscle problems which is also known as “tardive dyskinesia”. After taking this prescribed medicine the person will be able to move his muscles. However, the muscle problem that is “tardive dyskinesia” will not be curable even after taking metoclopramide. The main risk of this particular medicine is it can be able to cause that muscle problem (Gencbas, Bebis & Cicek, 2018).

However, this medicine can be taken for a short period only. This medicine is often prescribed for the symptoms of general problems such as vomiting, nausea and stomach emptiness. However, the care provider always refers to this medicine for the treatment of these general problems but the provider always suggests the care person not to take the specific medicine for more than 10-12 weeks. Too much metoclopramide can cause muscle problems. The care provider also prescribed morphine for the cause of headache. This morphine is known as a powerful painkiller for stress related pain and strong headache problems (Joseph, 2017). In addition, morphine generally works by its functionally blocking pain signals that are coming from nerves.

However, there are a few side effects while taking morphine as a medicine also. The side effects that are caused by morphine’s are major sleepiness and feeling sick. Morphine can be provided only if it has been prescribed by the care provider as it is known as a strong drug. Morphine’s generally come with two types of tablet mode that is known as fast-reacting and slow-reacting and others are capsule and liquid format.

Information Collected from The Case Study

In the first section it has been described about the general problems of the care person with the general problems and after that two morphine’s have been prescribed to him by the care provider (Rezende, Santos & Medeiros, 2016). After taking morphine and metoclopramide the condition of that care person has gone worse as he was suffering very critical headache problems as well the vomiting problem has increased more. The description has said that he has vomited in the entire bed as well he has also collapsed due to his sick condition. After the realization of the condition, the care person was taken to the hospital. After the admission to hospital T39 has been given to the care person. This specific medicine generally used for “antiphospholipid syndrome”. After the medicine “P 120” has also been given which helps in reducing fever as well pain (Geravandi, 2018).

However, this medicine has been used for various common diseases treatment such as common cold, body ache and headache. The “P-120” generally stands for paracetamol which can be given from the care provider with a quantity of 120 mg. In addition, the respiratory rate of the care person has been checked and the term refers to “RR 120”. The normal respiratory rate of a care person is 8-12 breaths per person. In addition, BP. 170/90 has been checked to the care person. The actual identification of blood pressure can be counted as 140-150/90-100 is known as hypertension at a mild level. However, the information collected from the care person’s blood pressure rate confirms that he got a bp rate of 170/90 (Urumova, Margosyan & Zheleva, 2018).

After the identification of blood pressure, the person has been provided an oxygen saturation test which should be taken in a room air condition of 90% air saturation. In this following test, the hemoglobin rate in oxygen has been checked with this SpO2 test. In addition, the hemoglobin rate sufficiency in oxygen as well in blood has been identified and the less efficiency will trigger the test as fall of hemoglobin. After the completion of oxygen saturation test hyperglycemia test will be taken for the reason of diabetes identification. This test generally occurs in the situation of glucose level of blood dropping low percentage that can be identified as less than 4mmol/l and the needful thing to do is taking a hypoglycemia test. In addition, this test will help the falling of glucose rate but after taking the test the care person will be feeling sick.

After the diabetes identification test the pupil reaction s are identified. The most common pupil reaction in this condition is known as “PERRLA” which identifies round, equal as well reactive function of pupil. For this test the test taker needs to check the pupil size, equality, shape and position (Blomberg, 2016). The response of the pupils will be taken in bright light. In addition, this test should be taken in a room where lights are dimmed. The test giver should be engaged in a distinct object. After the pupil test has completed, the photophobic test will be taken place. In this test, light sensitivity of the care person should be identified where there will be a few light sources such as sunlight, incandescent light as well fluorescent light that may cause the person discomfort (Dwisatyadini, Hariyati & Afifah, 2018).

However, one of the common symptoms in this situation has been associated with medical emergencies and the identification of light sensitivity. After the completion of photophobia test Glasgow coma test will be held. This coma test will be taken for the purpose of identifying the consciousness level. However, it helps to gauging brain injury also. In addition, GCS is known as an objective function for the identification of subsequent consciousness level. The information from the case study shows that the care person has level 3 in eye opening, level 3 in verbal response and level 5 in motor response. This response describes that the specific person has “to sound: in eye opening as well “words, not coherent” in verbal response and “localizing” in motor response. In addition, the final GCS level has been counted by calculating the sum of these numbers that is 3,3,5.

After the completion of GCS level nuchal rigidity will take place. In this condition, nuchal rigidity stands for the inability of flexibility of neck in forward direction due to the reason of rigidity (Mangare, 2016). However, after the completion of all these tests the care person has ordered a few things that are blood cultures, FBE, E&U, LFT, Glucose level, platelet count. The IV therapy also has been ordered by the person and this term refers to such a therapy which is responsible for delivering fluids into the vein. It can be delivered through injection by using a syringe. In addition, IV therapy for antibiotics has been ordered. Dexamethasone has also been ordered as it is used for the prevention of various allergic reactions, nausea, vomiting issues. This can be provided for general health related issues. The IV paracetamol has also been referred to as the solution of treating moderate pain fever. In addition, the hyperthermia causes can be treated with paracetamol iv. Ct scan and MRI scan has been done. After all the tests and therapy completion the identified diagnosis is known as: Bacterial Meningitis”.

Clinical Care - Part 2

Nursing Problem

Nursing Problem

Goal

Intervention

Rationale Evidence based

Expected Outcome

  1. Staffing - Staffing in medical workplaces is a major problem nowadays. 

ST- A working environment should be provided as well the recruitment of more staff should be scheduled.

LT- The goal is to recruit more nursing staff as well providing a good relatable working environment so that the staff will get job satisfaction and provide their care effort in medical workplaces.

1. s

1.The work environment is not up to the mark

2. The staffs are not getting enough opportunities

3. The management team is not coordinating with the staff

4. The staff team is not satisfied

5. The organization culture is not attracting them

The work environment may not be that much satisfactory to attract the staff to stay longer. In addition, the recruitment process may be differing from other recruitment processes in other sectors. ( Oates, Drey & Jones, 2017).

1. The staffs should be organized

2. The lack of staffing problems should be resolved.

3. The candidates for the process will get the opportunity.

4. The staffs are being satisfied with the environment

5. The staffs will be able to give more effort

Too much working hours

ST- The working hours of staffing has need to be changed as well the stuff should be organized and need to be habituated for giving a little more effort even in critical situation

LT- the long-time goal should be organizing the staff management and make them realize a few changes that should be needed in the long term adjustments.

The schedule of time management should be organized in a way so that the staff are satisfied enough to provide their effort in the workplace. In addition, the time schedule needs to decrease as per individual’s situation.

There are various situations may have appeared when the staffs are unable to provide effort for the duration of their more working hours. There can be severe conditions in which they need to finish their work fast and attend other works. In these specified situations, the working hours may have been affected by the staff.

The rescheduling of working hours can be good for both management and staffs. However, it will adjust the job satisfaction of the nursing staff and they will be able to give more effort in this situation if they find that the working hours have been adjusted. They will be able to give more effort and the working hours.

A couple of nursing problems has been discussed above. In addition, the nursing problems has been addressed above where a few interventions have been given. The goals have been divided into two parts such as long -term goals and short-term goals. In these goals we have decided about the future aspects that should be completed (Nantschev & Ammenwerth, 2020). The nursing section has included several interventions that are identified as to prevent these issues. The intervention identifies the reasons for the issues that are going on. It simply describes the reason how the issues are happening. The rationale column also has been described. In addition, the rationale section has identified the prevention of these issue has been described. However, the outcomes of these issues have a positive impact. In addition, after the prevention and intervention, outcome has been described in the NANDA framework.

On the other hand, the thing that the concerned for is the prevention of the issue of staffing as well as the duration of working hours. As per Pryor & Clarke, (2017) the outcome will be considered after the successful prevention and adjustments of these issues. The issues can be prevented with organizing the management as per time schedule. In addition, the work environment should be organized so that the staffs should be more efficient and willing to give their full effort in this situation. On the other hand, the staffs will be able to find the comfort zone in the organized workplace. However, the staffing management should be recruited by the logical recruitment process. In this process every staffs should be recruited as per their merit and working experience.

Clinical Care - Part 3

The Reflection

In this section, a short reflection should be studied in where we need to provide the findings. In this section, the information that we have gathered from the case study it has been found that the person has need to be go through with a diagnosis policy as well there are a few medical therapies that should be taken after the generic problems identification. However, in this section we have found that the care person was going through several common diseases such as nausea, vomiting and headache and after the checkup the care provider has prescribed an injection and prescribed morphine tablets. In this case we have also found that after taking the medicine the care person has suffered a serious issue such as a powerful headache and worse vomiting condition.

In this condition the care person was needed to take to the hospital and a several tests has been given for the identification of a few critical conditions such as checking of diabetes, oxygen saturation, hemoglobin rate, blood pressure rate and a few things has also been checked which included the pupil condition and photophobia. However, the completion of a few therapy that has been ordered by the care person has been mentioned earlier. These therapies may affect the situation of the care person as he may fall sick due to these therapies. After all the information that has gathered in part 1, the nursing care plan has been described part 2. In this section two nursing problems have been reflected that have been occurring in the workplace. The NANDA (North American Nursing Diagnosis Association) framework has been given where five columns have been attached which include the problems, the goals, the intervention, the rationale and the outcome for the prevention of the problem. There are two nursing problems that has been discussed above with the help of NANDA framework are staffing problems and too much working hours in the workplace.

References for Clinical Care

Blomberg, K., Griffiths, P., Wengström, Y., May, C., & Bridges (2016). Interventions for compassionate nursing care: A systematic review. International journal of nursing studies62, 137-155.DOI: https://doi.org/10.1016/j.ijnurstu.2016.07.009

Dwisatyadini, M., Hariyati, R. T. S., & Afifah, E. (2018). The effects of the application of SIMPRO on the completeness and time efficiency of nursing documentation in the outpatient instalation at Dompet Dhuafa Hospital Parung. In IOP Conference Series: Materials Science and Engineering (Vol. 332, No. 1, p. 012034). IOP Publishing Ltd. Retrieved from https://iopscience.iop.org/article/10.1088/1757-899X/332/1/012034/pdf

Gencbas, D., Bebis, H., & Cicek, H. (2018). Evaluation of the efficiency of the nursing care plan applied using NANDA, NOC, and NIC linkages to elderly women with incontinence living in a nursing home: a randomized controlled study. International journal of nursing knowledge29(4), 217-226. Retrieved from https://www.researchgate.net/profile/Ozge_Iseri/publication/312046172_Karadag_et_al-2015-International_Journal_of_Nursing_Knowledge/links/586ce1cf08ae8fce491a102a/Karadag-et-al-2015-International-Journal-of-Nursing-Knowledge.pdf

Geravandi, S., Soltani, F., Mohammadi, M. J., Alizadeh, R., Valipour, A., Hoseini, A., ... & Ghomeishi, A. (2018). The effect of education on the nursing care quality of patients who are under mechanical ventilation in ICU ward. Data in brief16, 822-827. DOI: https://doi.org/10.1016/j.dib.2017.11.090

Joseph, J. (2017). The need of nursing care plans in hospitals. Indian J Basic Appl Med Res [Internet]6, 318-22. Retrieved from https://ijbamr.com/pdf/March%202017%20318-322.pdf.pdf

Mangare, N. L., Omondi, A. L., Ayieko, O. A., Wakasiaka, S., & Wagoro, M. C. A. (2016). Implementation of the Nursing Process in Naivasha District Hospital, Kenya. American Journal of Nursing5(4), 152-157.Retrieved from file:///C:/Users/VIDINI002/Downloads/10.11648.j.ajns.20160504.15.pdf

Nantschev, R., & Ammenwerth, E. (2020). Availability of Standardized Electronic Patient Data in Nursing: A Nationwide Survey of Austrian Acute Care Hospitals. Studies in Health Technology and Informatics272, 233-236. Retrieved from https://www.researchgate.net/profile/Renate_Nantschev2/publication/342639615_Availability_of_Standardized_Electronic_Patient_Data_in_Nursing_A_Nationwide_Survey_of_Austrian_Acute_Care_Hospitals/links/5f0590a14585155050948186/Availability-of-Standardized-Electronic-Patient-Data-in-Nursing-A-Nationwide-Survey-of-Austrian-Acute-Care-Hospitals.pdf

Pryor, C., & Clarke, A. (2017). Nursing care for people with delirium superimposed on dementia. Nursing older people29(3), 18-21. Retrieved from http://nrl.northumbria.ac.uk/id/eprint/30550/1/PryorAAM.pdf

Rezende, L. C. M., Santos, S. R. D., & Medeiros, A. L. (2016). Assessment of a prototype for the Systemization of Nursing Care on a mobile device. Revista Latino-Americana de Enfermagem24.Retrieved from https://www.scielo.br/pdf/rlae/v24/0104-1169-rlae-24-02714.pdf

Urumova, S., Margosyan, Z., & Zheleva, E. (2018, December). Plan For Nursing Care In Cases Of Intoxication With Cleaning Detergent. In Varna Medical Forum (Vol. 7, pp. 370-374). Retrieved from file:///C:/Users/VIDINI002/Downloads/6790-19590-1-SM.pdf.

Oates, J., Drey, N., & Jones, J. (2017). ‘Your experiences were your tools’. How personal experience of mental health problems informs mental health nursing practice. Journal of psychiatric and mental health nursing24(7), 471-479. Retrieved from DOI: https://uhra.herts.ac.uk/bitstream/handle/2299/19645/Oates_et_al_2017_Journal_of_Psychiatric_and_Mental_Health_Nursing_1_.pdf?sequence=3&isAllowed=y

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