Clinical judgement and handover

There are two (2) parts to Task 5.

Part A:

When removing Rosie’s breakfast tray this morning you notice she has not eaten and ask her why. She states she slept badly overnight as she could not get comfortable lying down and she is feeling anxious about Joe being on his own. As a result she is now feeling nauseous and unwell. She denies pain apart from slight indigestion which she often gets lately but it usually goes away on its own. She is feeling irritable so you leave her to rest.

On your return you find Rosie extremely agitated and trying to get out of bed stating she has to call Joe. Visually assessing Rosie as you assist her back into bed you notice Rosie’s skin appears very pale and slightly bluish grey. She appears dyspnoeic and slightly breathless with shallow, rapid respirations. Her skin feels cool and moist and her ankles appear swollen.

On further assessment you find:

Respiratory rate is 28 – 32 breaths/minute
Oxygen saturations are 84% on room air
Heart rate 140 beats/minute.
Radial pulse is weak and thready and difficult to palpate.
Blood pressure is 90/80 mmHg but faint and difficult to detect clear margins.
In grammatically correct sentences and topic paragraphs,

Identify
o What you think is happening
o Your immediate nursing actions and interventions o The reason for your actions and interventions

Part B:

An important legal requirement of nursing practice is to effectively and succinctly communicate relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.

Once Rosie’s condition has been stabilised, the doctors arrange to transfer Rosie to the Coronary Care Unit for closer monitoring and management.

Using the ISBAR format, information from the handover you initially received and the additional information above:

Write a written handover that clearly and succinctly outlines the important information the coronary care unit needs to know about Rosie

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