lieus becoming actual problems. These n in some cases happen simultaneously. AL
ID: 238421 • Letter: L
Question
lieus becoming actual problems. These n in some cases happen simultaneously. AL THINKING EXERCISES Your client, 21-year-old Tiffany, delivered a baby girl 3 hours ago, and has just told you that she feels nause- ated. This is the first time she has reported this symp- tom. What additional information would you ask her, or seek from other sources, before reporting this informa- tion to your team leader? What observations would you make? Explain the rationale for your choice of questions and observations. 1. 2. You are currently working with two clients who have had a stroke. Both clients are paralyzed on the right side. Based on your understanding of holistic nursing and of individualized client care, describe factors that you would expect to consider when working with each client to design a plan of care.Explanation / Answer
1) Firstly it is important to understand that as she is reporting nausea after childbirth it is called postpartum nausea. This has several reasons:
1)/There is a rapid change in the hormones which can lead to increased secretion of acid in the stomach.
2) Dehydration due to loss of fluids during the process of labor and breastfeeding too which is needs to be compensated.
Additional information
: Previous history of vomiting especially during pregnancy/ hyperemesis gravidarum as it is very common to have such symptoms during pregnancy and if its severity is untreated then it is likely to continue after delivery.
Any conditions which causes this tendency to vomit for example. Any surrounding factor ( smell or sight).
Physical assessment: Blood pressure , assessment for dehydration skin turgor,dry lips and tongue, and urine output ( important to rule out dehydration).
Scenario 2#
CVA is the rapid loss of brain function due to disturbances in the blood supply in the brain. So we have two patients having the same condition but still the care would be different in terms of these factors:
The extent of severity: Even though both have suffered the same condition it Is important to measure the severity of the affected .This is essential for providing good rehabilitation. They are:
1)The extent of sensorimotor impairment like
Dysphagia ( the inability to swallow) - Assessment should be made to understand who has good gag reflex and can be fed normally or who requires tube feeding.
Visual field loss : To assess any loss of vision after care which can pose a threat to the safety of the patient.
2)Activities of daily living
The ability to perform activities of self care of both the patient should be assessed to understand who needs an extra support.
3)Communication: Aphasia(inability to speak) is a residual affect and needs to be screened among both the patient to provide care accordingly ( ability to communicate by self or requires an interpreter)
4)Nutrition and hydration: To be assessed to intervene accordingly, support with NG feeds or liquid feeds, or solids if no impairment to swallow.
5)Hygiene:Ability to do self care activities like maintaining oral hygiene or needs oral care by the nurse.
6) Urinary or bowel incontinence: Presence of cathether or its necessity, ability to void without retaining, bowel assessment for the need of training of bowel habit.
7)Pressure care : Assess for the severity and the extent to which regular pressure care is required to prevent bed sores.
8)self management: Care of oneself and promotion of self harnessing ability can be assessed.
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