The Care Plan For Nursing Assessment Tools

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1. Introduction: In this case study, there is a patient named Mr. Wilson who is a 70 years old man. He stated that he had difficulty in breathing and caught a ‘flu’ a week ago. Currently, he has been observed pitting oedema on his lower legs. In addition, the patient had history of heart attacks, which has been diagnosed with congestive heart failure. The case study will provide a complete care plan for the patient. Its aim is to provide a better quality of care for the patient as well as promoting holistic treatment of the patient. The report will firstly assess the patient’s condition by two nursing assessment tools while offering rationale for choosing these assessment tools. The client’s health problems will then be identified and…show more content…
In addition, the client has already been observed oedema in lower legs. Therefore, fluid balance chart, which can record intake and output of fluid, can help to integrate patient’s health status. 3. Client Health Problems: This section is to identify three client health problems the patient has and sort by prioritization. 3.1 Impaired gas exchange. The most serious health problem that the client has is impaired gas exchange. According to Sue Galanes (2007), impaired gas exchange is result from the balance between ventilation and perfusion is offset by a certain condition which affects the efficiency of the gas exchange. On account of client has congestive heart failure that can contribute to dyspnea, which means the efficiency of gas exchange is decreased. One of the significant defining characteristics of impaired gas exchange is dyspnea (Sabtu, 03 Agustus 2013). In addition, it was hard for the patient to talk in long sentence due to difficulty in breathing. Hence, impaired gas exchange is one of the health problems that the client suffered from. In regards of O2 is the basic element that all of cells and organs need, it can be considered as a fuel of human body. Therefore, impaired gas exchange is the most severe health problem the patient has currently. 3.2 Excess Fluid Volume. The second health problem that the client has is excess fluid volume. Fluid volume excess occurs from an increase in total body sodium content and an increase in total body water
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