Question

4. Initial Focused Assessment After reviewing the patient background and nursing report, you are ready to assess your patient's current status. Under each category, identify how you would target your assess- ment, and what you would expect to find for the patient. History Are there any questions you need to ask the patient or family to obtain relevant data? Physical Exam General appearance: • Integumentary: • HEENT: - Respiratory: CV: Breasts: - Abdominal: Patient Safety/What's Wrong with

Answer 1

Detailed history makes diagnosis proper and accurate with syncope. Ask the patient and family history of any sudden death, hypotension, old age, and CVD and family history of neurological disorder.
Collect patient history of Autonomic failure and its syndrome, history of diabetes and any drug and alcohol use to find orthostatic hypotension and ECG for finding abnormalities for arrhythmic syncope.
Plan of care:
-the patient is at bed rest so preventing fall and injury is important.keep necessary items like call bell near to the patient bedside and where they reach out easily for help, make the side rails up to X3, make the bed level lower with lock position, make one assistance to accompany patient always.
-Monitor patient level of conscious and neurological symptoms to promote safety
-Monitor patient BP, respiration and o2 saturation continuously to avoid hypoxia and hypotension
-change the patient position frequently to avoid pressure ulcer
-check the patient BP in supine, sitting and standing position to find the orthostatic hypotension.
-check the patient glucose level every morning and bedtime
-Provide adequate fluids to prevent hypotension
-Administer medications as per doctors advice