• Identify the importance of utilising a holistic approach during a nursing assessment and how assessment is relevant in the nursing process
• Identify three aspects of a holistic nursing assessment and explain the reasons to incorporate the aspects during a nursing assessment
• Demonstrate the interrelationship of the chosen holistic aspects
• Demonstrate an understanding of the Australian Nursing and Midwifery Council National Competency Standards for the Registered Nurse and provide some examples of how they apply when undertaking a holistic nursing assessment
The sister of C.K. called to report her 71-year old brother came down with a fever 2 days ago. Now he has shaking chills, productive cough, inability to lie down to sleep because “he can’t stop coughing.” C.K is examined by the hospital’s Primary Care Clinic provider, is diagnosed with community acquired pneumonia and admitted to your floor. Your physical assessment findings are as follow: C.K. vitals signs are 154/82, 102 deg F. 28 respirations, SaO2 88%. He is oriented to person place and time. He has decreased breath sounds on the left lower lobe anteriorly and posteriorly, coarse crackles left upper lobe. His nail beds are dusky on fingers and toes. He has productive cough and green colored sputum and complaints of pain in his right chest when he coughs. C.K. seems to be well nourished and adequately hydrated, although he complains of feeling tired. He is a lifetime nonsmoker, nondrinker. He has never gotten the Pneumovax or flu shot. He reports no known drug allergies. The provider orders the following: general diet, vital signs every 2 hours. Maintenance IV of D5 1/2NS at 125cc/hr, ceftriaxone 1g IV once a day for 10 days, titrate oxygen to maintain oxygen saturation >90%. Obtain sputum for culture and sensitivity.
Draw the following labs: CBC and basic metabolic panel (BMP). Obtain a chest Xray now and in the morning.