Nursing Assignment

Nursing Assignment

Confidentiality and privacy of personal health information are vital nursing standards. As a nurse, one has an individual responsibility to maintain and keep patients' personal information legally and ethically confidential and private. As one of the patients' rights, a nurse should respect the patient and their confidential information. Patient confidentiality can be breached by failure of understanding the personal health information protection Act, which explains the contents of personal health information, how the Act can be implemented in the health continuum, and how the information affects nurses (Anckley, 2019). Personal information of patients should only be disclosed in certain circumstances and mostly under a disclosure order. The order allows a nurse to release a patient's information to another custodian (Anckley, 2019). Providing patients' personal information to unauthorized individuals without consent is considered professional misconduct by the nursing ACT 1991 (Lewis, 2018). The nursing standard is accompanied by several factors like informed consent and decision making, rights maintenance, avoiding the potential for harm, and maintaining quality care delivery. Nurses should embrace leadership, better communication, professionalism, and nursing patient relationship development to promote confidentiality.

Falls practice guidelines are nursing standards set to prevent and manage older adults and patients at risk of falling. The RNAO has set best practice guidelines to reduce falls and injuries in older adults. Based on the evidence, the rate of falls that may lead to injury is studied and has proved to relate to nursing quality indicators (Lewis, 2018). A study proved that preventing falls and reducing injury from falls led to a decrease in fall-related injuries and a 100 percent screening of falls risk on admission. According to the Lewis, (2018), the Interdisciplinary approach has proved effective in preventing and reducing falls. Additionally, for nursing care plans, the plans have been personalized to reflect the wishes and goals an older individual expects.

Answers

1a) Mr. Harris was admitted on September 11, 2021

1b) DNR is an abbreviation for Do Not Resuscitate order. It means that if a patient's heart stops beating, medical personnel/ staff should not perform cardiopulmonary resuscitation to try and maintain the patient’s life.

1c) NPO- Nil per Oral means that the patient should not take any food or drink through the mouth

2. NKA is an abbreviation for no known allergy, which presents information that the patient had never had a drug allergy they can confirm and so drugs they have used before did not harm themselves.

3.

1.  Deep vein thrombosis presenting as a Blood clot in the left leg.
2. Visually impaired
3. Pain which he rates at  7/10
4. Diarrhea the previous day
5. Redness to his coccyx
6. He is unsteady on his feet
7. The left leg is swollen
8. Absent pedal pulse to leg foot caused by reduced circulation.

4. Visual impairment because he may not see, causing him to stumble on items.

     He has Unsteadiness on his feet due to the swelling, which may cause him to fall due to a lack of balance.

5a) Deep vein thrombosis

       Swelling on the left leg

5b) Graded 7/10

6. Providing sufficient lighting for the patient’s environment. Due to the vision impairment, the patient may need more light to identify risks that may make him fall (Potter et al., 2020). Night light should be present in the patient’s room to accommodate light needs for the patient. Enough lights help avoid injury from falling.

7a) STAT means in urgency or immediately, so an ECG should be done to the patient immediately.

7b) ECG is an abbreviation for electrocardiogram, a cardiac functioning and rhythm test.

8. The subjective data from Mr. Harris's presentation is that he has pain, impaired sight, and swelling on his left leg. Additional subjective data include diarrhea, no known drug and food allergies, morphine use, nil per oral, and do not resuscitate code. The objective data obtained from the examination is that he is alert, oriented, and unsteady on his feet. His vitals are stable at a blood pressure of 120/70, pulse rate of 77, respiratory rate of 20 and temperature of 36 degrees Celsius. The oxygen saturation is 98% with a soft, non-tender abdomen, clear chest and normal heart sounds. On examination, the left leg is warmly swollen, and the pedal pulse is absent.

9. Normal saline at 100mL/hr.

10. QID, on prescription, means four times a day, meaning that the drug should be taken after every 6 hours. So the next dose, he will take it at 1600hrs.

11. By 1200, the patient would have had 500 ml of normal saline solution. For every one hour, they receive 100 ml, so within 5 hours, they'll get 500ml.

References

Potter, P. A., Perry, A. G., Stockert, P. A., Hall, A., Astle, B. J., & Duggleby, W. (2018). Canadian Fundamentals of Nursing-E-Book. Elsevier Health Sciences.

Anckley, B. J., Ladwing, G. B., & Makic, M. B. F. (2019). Nursing diagnosis handbook: an evidence-based guide to planning care Ed 11 (77).

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2018). Medical-surgica nursing in Canada-E-Book. Elsevier Health Sciences.