92y/0 Male, has a history of Alzheimer’s Disease, NIDDM, AF, GORD, CCF, mild depression, and previous hernia and AAA repair and one week ago was diagnosed with advanced CA of the liver and metastases in the pancreas, lungs, and brain. For discharge home on care of the dying pathway with the support of the community nurses. Assessment findings: Palliative care phase 3: Deteriorating. Symptom Assessment Scale (SAS): Pain 5; Nausea 2. Problem Severity Score (PSS): Pain 2; Other symptoms 1; Psychological/Spiritual 0; Family/carer 1. RUG-ADL: 18. AKPS: 20. Airway, breathing, and circulation intact. John is no longer mobile. He remains confused. He requires full assistance with activities of daily living, nutrition, and toileting. Jo is lethargic, has generalised body pain and nausea. John is 50 kgs and is 163 cm tall. Jo has a stage 2 pressure injury on his sacrum. John does not identify with any particular religious denomination however his daughter advises that he is strongly spiritual, and this will need to be considered in planning his care. list the normal and abnormal subjective and objective data that you have collected from the scenario provided. Identify two nursing problems of highest priority. For the nursing problem of highest importance: Establish a minimum 3 goals for each nursing problem that include all 5 elements of the SMART acronym. List a minimum 6 actions (minimum 6), in order of priority that you would undertake to achieve that goal. Specify if the action is a dependent or independent nursing action. You must consider the holistic requirements of the patient. Provide a rationale that associates the pathophysiological and psychological principles with each selected nursing action. Describe how you would evaluate the effectiveness of the care provided (i.e. how will you know that your actions were beneficial to the patient?) A minimum 1 evaluation of the outcomes for each action.
92y/0 Male, has a history of Alzheimer’s Disease, NIDDM, AF, GORD, CCF, mild depression, and previous hernia and AAA repair and one week ago was diagnosed with advanced CA of the liver and metastases in the pancreas, lungs, and brain.
For discharge home on care of the dying pathway with the support of the community nurses.
Assessment findings:
Palliative care phase 3: Deteriorating.
Symptom Assessment Scale (SAS): Pain 5; Nausea 2.
Problem Severity Score (PSS): Pain 2; Other symptoms 1; Psychological/Spiritual 0; Family/carer 1. RUG-ADL: 18. AKPS: 20.
Airway, breathing, and circulation intact. John is no longer mobile. He remains confused.
He requires full assistance with activities of daily living, nutrition, and toileting. Jo is lethargic, has generalised body pain and nausea.
John is 50 kgs and is 163 cm tall. Jo has a stage 2 pressure injury on his sacrum.
John does not identify with any particular religious denomination however his daughter advises that he is strongly spiritual, and this will need to be considered in planning his care.
list the normal and abnormal subjective and objective data that you have collected from the scenario provided.
Identify two nursing problems of highest priority. For the nursing problem of highest importance:
- Establish a minimum 3 goals for each nursing problem that include all 5 elements of the SMART acronym.
- List a minimum 6 actions (minimum 6), in order of priority that you would undertake to achieve that goal. Specify if the action is a dependent or independent nursing action. You must consider the holistic requirements of the patient. Provide a rationale that associates the pathophysiological and psychological principles with each selected nursing action.
- Describe how you would evaluate the effectiveness of the care provided (i.e. how will you know that your actions were beneficial to the patient?) A minimum 1 evaluation of the outcomes for each action.
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