Xu_xum08266299_Assess Client Case Study

nursing assessment

1. The primary nursing model means a nurse will provide and coordinate total care to his/her allocated patient during the patient's hospitalisation including the

administration of medication, communicate with other allied health professionals and make decisions according to medical assessments (Fernandez et al 2012).

The team nursing model refers to a number of specialized and experienced nurses working collaboratively and cooperatively under a strong leadership to deliver a high standard of care to a patient (Lanyon 2014 ③). In Mr Guzman's case, he might require special pain management, neurological nursing and wound care. A group of nurses with specific knowledge and experience would provide various aspects of nursing care to achieve more effective and productive outcome for him. I think a team nursing model will be more suitable for Mr Guzman during his stay in HDU. Word Count: 137

2. Mr Guzman apparently suffers from pain all over his body due to his multiple injuries and surgery wound. Administrating paracetamol will be the first option because he could not state his pain score.

His fever might be related to the infection on his wound or respiratory infection. Checking the wound for infection and reporting any abnormalities to the RN.

He is short of breath and wheezes when he inhales due to head trauma and fever. Sitting him semi-fowler and commencing the oxygen therapy with Salbutamol (Tiziani 2010). Green sputum he coughs up might due to his respiratory infection. He has irregular heartbeat and hypotension more likely caused by his chest injuries. Elevating his feet to allow more blood flowing back to the heart should be done for his hypotension. Amiodarone is an anti-arrhythmic agent used to stabilise the heart rate (Tiziani 2010). It is necessary to check with the doctor before administrating the drug because Mr Guzman already presented hypotension symptom (Tiziani 2010). His urine output of 15-30ml/hr of blood stained urine, might be due to his kidney trauma. Bladder ultrasound should be performed for his urinary retention (urine output < 40ml/hr) (Treagus 2013).

3. Severe haemorrhage and hypovolaemia can be a result in accidental

disconnection of an arterial line insitu. The nursing staff should check the site and ensure the connection before starting each shift. Immobilise the arm with an arm