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Acute Care Essay

3142 words - 13 pages



For this assignment I have chosen to use a patient on a Medical Rehab Ward that became acutely unwell very suddenly and was eventually diagnosed with Urinary Sepsis before being transferred to an Acute Medical Ward for further treatment. The purpose of this assignment is to show how I as the nurse, managed the situation in the assessing of the patient from the onset of their symptoms using the Airway, Breathing, Circulation, Disability framework. The planning and implementing of the care required and evalutaing constantly to ensure that the care provided is working and how I communicated with the relevent medical staff using the ISBAR tool of ...view middle of the document...

The medications she is recieving for these can be found in Appendix 1. The aim whilst in this ward is to effectively treat the ulcers which the Public Health Nurse had been unable to do due to their severity, reduce her weight in conjunction with the Dietician and work on improving her mobility with the Physiotherepay team as this has become severly comprimised in that she has become bed bound and is only transferrable to chair using full hoist. Whilst the patient is in pain upon movement for example when nursing/care assistant staff are assisting with hygiene needs or changing her dressings, her mood is upbeat she is chatty and hopeful about the outcome of the treatment of her Ulcers. She also understands that her weight needs to be reduced as it is having an impact on her overall health not just on the Oedema and she is willing to tackle this issue. Her vitals are and have been within normal ranges since her admission to this ward and the plan from her team is for discharge in 12 weeks however this will remain under review depending on the patients progress, so far she has been on the ward almost 3 weeks.

Given the nature of this ward, once daily obs are sufficient unless otherwise required. On the morning in question the nurse takes the vital signs of the patient and notes that the patient is pale. At 8am upon taking the vitals, all are within normal range except for a slight spike in the patients temperature to 37.8 degrees and whilst this scores a 0 on the EWS it is still above the basline for the patient who has a regular temperature of approximately 36.4. She asks the patient how she is feeling and she replies she is feeling tired this morning as she didn't sleep too well overnight as she was quite restless. The nurse then records the vital signs on the EWS sheet noting that the patient's bowels have not opened sine the previous morning nor has she passed urine since the night before. The nurse asks the patient if she would like asistance with a wash but the patient refuses saying she doesn't feel up to it. She advises the patient to try to get some rest after she has had her breakfast that she will come back and check on her later on. The nurse then tells the Clinical Nurse Manager that the patients temperature is elevated, that she hasn't slept properly and that she is pale that she will recheck her vital signs in 4 hours as she feels that the patient isn't well. Throughout the morning the nurse keeps an eye on her patient, she notes that she did not eat much of her breakfast and has been sleeping. Before lunch, the nurse decides to recheck the patients Vital Signs, she is sleepy but rousable. Her temperature is risen to 38.1 scoring a 1 on the EWS, all other vitals are within range at this time, Paracetamol PRN is given in order to reduce the temperature. The patient has still not passed urine so the nurse encourages her to drink some water and have milk with her dinner which will be served shortly. The nurse logs the score on the...

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