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Assessment1: GuidedScenarios

Mary bol (n9099409)

GuidedCase Scenarios



  1. In case of Jamie, the primary problem ids breathlessness or hyperpnea. The assessment data which confirms the same are admission time health status which implicates high breathlessness. The wheezing sounds and cough imply lung’s congestion due to mucus or cough clogging the alveoli (Chaitlow, 2013). His respirations are deep, no cyanosis implicates this is due to less oxygen supply to the body.

  2. The immediate intervention is to record the pulse rate followed by recording of respiration rate. Since he looks pale and his lips look pink this signify the body is experiencing hypoxia even after oxygenation. The respiration rate must be 1/4th of the pulse rate. Any discrepancy in this rate can help us in better diagnosis and interventions can be designed (Boyles, 2011).

  3. The advantages of using nasal prongs are limited to oral feeding of patient and patient can talk normally while on oxygenation (McCarthy, 2011).

  4. The following assessment data implies the nasal prongs need to replaced. The breathing patterns such as deep breathing, forcibly breathing, pink color of lips and pale color suggests the patient is suffering from hypoxia and not sufficient oxygen is getting to the blood. Secondly through nasal prongs the amount of oxygen which goes to Jamie’s body is only a part of inspiratory flow which is being generated by Jamie. Thus very low percentage of oxygen gets into the body for which the above symptoms are observed (Roca, 2010).

  5. The following changes in behaviour imply decreased oxygen.

  • Cyanosis or bluish discoloration of the skin, deep breathing with force, wheezing sound, pain or tightness in chest and back, feeling very weak and headache (Wright and Leahey, 2012).


  1. The primary assessment with regard to safety will be her assessing her mobility degree, pain and her confidence with regard to walking after her arrival to rehabilitation unit (Hordam, 2011).

  2. The factors which imply she is at risk of fall – she needs assistance from the nurse in her right elbow to walk. Secondly, she still fears to walk which can lead to psychological fear and stress (Healee, 2011).

  3. The interventions would be collaborative in nature (Healee, 2011).

    1. Asking her to do small exercises such as contractions and expansions of legs, buttocks and ankle pumps.

    2. The hip muscles movement must be monitored with a physiotherapist

    3. While going for toilet and bathroom, patient must be assisted. The weight bearing status must be checked.

  4. Since she had her right hip replaced, thus the weight bearing status of right leg must be low. Due to the pressure on right leg, the pressure injury may have occurred.

  5. To prevent further damage to the heel the following assessments and interventions need to be done. After knowing from surgeon the type of hip replacement done, the weight which can be taken up by right leg must be known. This will help in assisting her while exercising. Asking the patient to keep padded stockings on in order to have less pressure on her heel. Asking her to move the legs with physiotherapist prescription as blood flow to the legs are impaired after hip replacement surgery.

  6. The swelling at heel, skin texture and color, pain sensation at heel must be noted while assessing the patient heel. Any type of inflammation can be as a consequence nerve blockage or blood clotting. The risk scores must be noted down for interventions.


  1. The four physical signs of dehydration which Clive should look after are – dry and sticky mouth, feeling weak and sleepy, scaly or dry skin and increased thirst.

  2. Fluid overload is commonly observed in chronic heart failure patients. Two physicals signs to be checked for Clive are – dyspnea or fatigue (McMurray, 2012).

  3. Nutrition is an important factor for patients with chronic illness. During chronic illness, more than one system gets affected. Thus, the body falls short of essential nutrients required to maintain homeostasis as well as to fight against different illness. Clive being suffering from chronic illness, his underweight can result into more dehydration and weakness. The body systems may wear out due to the negative effect of illness.


Boyles,C. M., Bailey, P. H., &amp Mossey, S. (2011). Chronic obstructivepulmonary disease as disability: dilemma stories. Qualitativehealth research,21(2), 187-198.

Chaitow,L., Bradley, D., &amp Gilbert, C. (2013). Whatare breathing pattern disorders?. Recognizing and Treating BreathingDisorders,1.

Healee,D. J., McCallin, A., &amp Jones, M. (2011). Older adult’s recoveryfrom hip fracture: a literature review. InternationalJournal of Orthopaedic and Trauma Nursing,15(1), 18-28.

Hordam,B., Pedersen, P. U., Soballe, K., Sabroe, S., &amp Ehlers, L. H.(2011). Quality-adjusted life years gained in patients aged over 65years after total hip replacement. InternationalJournal of Orthopaedic and Trauma Nursing,15(1), 11-17.

McCarthy,L. K., Davis, P. G., &amp O`Donnell, C. P. (2011). Nasalairways (single or double prong, long or short) for neonatalresuscitation.The Cochrane Library.

McMurray,J. J., Adamopoulos, S., Anker, S. D., Auricchio, A., Böhm, M.,Dickstein, K., … &amp Lamin, H. A. B. (2012). ESC Guidelines forthe diagnosis and treatment of acute and chronic heart failure 2012The Task Force for the Diagnosis and Treatment of Acute and ChronicHeart Failure 2012 of the European Society of Cardiology. Developedin collaboration with the Heart Failure Association (HFA) of the ESC.Europeanheart journal,33(14), 1787-1847.

Roca,O., Riera, J., Torres, F., &amp Masclans, J. R. (2010). High-flowoxygen therapy in acute respiratory failure. RespiratoryCare,55(4), 408-413.

Wright,L. M., &amp Leahey, M. (2012). Nursesand families: A guide to family assessment and intervention.FA Davis.