I: Arthur Charleston is a 52 year-old Aboriginal Wiradjuri man. Birth date 7/04/2022. MRN  102304 S: Arthur presented to the Emergency Department today following a fall at his home. Arthur has a contusion above his left eye and shows some disorientation to person, place and time and currently has a GCS of 14. Pupils are equal and reactive to light and motor function is equal on both sides in his legs and arms B: Arthur has a history of Type 2 Diabetes Mellitus and Hypertension. Arthur lives on his own and smokes 20 cigarettes a day. Arthur consumes 6 cans of full strength beer per day, and Arthur states he eats very little and enjoys take away meals most days. Allergies Nil Known. A: Arthur’s vital signs are;  Temperature 36.5 C  Respirations 12  Pulse 110 bpm  Blood Pressure 145/90  Sp02 92%  BMI 21  BGL 15mmol

Complete the documentation for Arthur based on the four (4) nursing diagnosis provided:  1. Uncontrolled diabetes due to poor nutrition. 2. Uncontrolled hypertension. 3. Shortness of breath due to history of smoking. 4. Disorientation due to fall at home and unfamiliar environment.

For each nursing diagnosis you need to provide the following points:

a. What main body system may be affected by the nursing diagnosis? You only need to identify one (1) system. .   b. The impact the condition will have on Arthur’s lifestyle; this could be a physical or psychological impact. c. What nursing care could you, as an EN, provide to assist Arthur with this condition? You may consider education, referrals to other healthcare professionals or general nursing care that may assist Arthur. d. What would the best outcome be for Arthur, if the treatment/care provided was successful? e. What other healthcare professional (other than a RN) can assist you to provide care for Arthur? List a different healthcare professional for each nursing diagnosis.

ANSWER

Comprehensive Nursing Documentation for Arthur Charleston’s Nursing Diagnoses

Introduction

Effective nursing documentation is paramount for providing holistic care to patients. This documentation for Arthur Charleston, a 52-year-old Aboriginal Wiradjuri man, aims to address his nursing diagnoses and provide a clear outline of the impact on his health, the nursing care required, potential outcomes, and collaboration with other healthcare professionals.

Uncontrolled Diabetes Due to Poor Nutrition

Main Body System: Endocrine System
Impact: The uncontrolled diabetes resulting from poor nutrition can lead to imbalanced blood sugar levels, contributing to fatigue, increased thirst, and frequent urination. Arthur might experience reduced energy levels, compromised wound healing, and an increased risk of complications like neuropathy and vascular issues.
Nursing Care: As an Enrolled Nurse (EN), I could educate Arthur about the importance of balanced nutrition and its impact on diabetes management. Referral to a dietitian for personalized dietary guidance and education on blood glucose monitoring techniques would be beneficial.
Best Outcome: Successfully managing diabetes through improved nutrition would lead to stabilized blood sugar levels, increased energy, and decreased risk of complications.
Collaborating Healthcare Professional: Dietitian

Uncontrolled Hypertension

Main Body System: Cardiovascular System
Impact: Uncontrolled hypertension can strain the heart and blood vessels, increasing the risk of heart disease, stroke, and kidney problems. Arthur might experience fatigue, headaches, and shortness of breath.
Nursing Care: I could educate Arthur about the importance of medication adherence and lifestyle modifications such as reducing salt intake and regular exercise. Collaborating with a pharmacist for medication review and adjustment could optimize his hypertension management.
Best Outcome: Successful management of hypertension would result in normalized blood pressure levels, reduced risk of cardiovascular complications, and improved overall well-being.
Collaborating Healthcare Professional: Pharmacist

Shortness of Breath Due to History of Smoking

Main Body System: Respiratory System
Impact: Arthur’s history of smoking can lead to lung damage, reduced lung capacity, and increased shortness of breath. He may experience reduced physical endurance and difficulty engaging in daily activities.
Nursing Care: I could provide smoking cessation education and resources to help Arthur quit smoking. Referring him to a respiratory therapist for breathing exercises and lung function assessment would be beneficial.
Best Outcome: Successful smoking cessation and respiratory therapy would lead to improved lung function, increased exercise tolerance, and a decreased risk of respiratory complications.
Collaborating Healthcare Professional: Respiratory Therapist

Disorientation Due to Fall at Home and Unfamiliar Environment

Main Body System: Nervous System
Impact: Disorientation can lead to anxiety, confusion, and compromised safety. Arthur might feel vulnerable and distressed in an unfamiliar environment, increasing his risk of falls and accidents.
Nursing Care: I could offer reassurance and provide information about the healthcare setting to reduce anxiety. Collaborating with a social worker to assess Arthur’s living situation and arrange support services upon discharge would be beneficial.
Best Outcome: Successful orientation to the environment, along with a safe discharge plan, would result in reduced anxiety, enhanced safety, and improved overall well-being.
Collaborating Healthcare Professional: Social Worker

Conclusion

Comprehensive nursing documentation for Arthur Charleston’s nursing diagnoses highlights the impact of his health conditions, outlines the nursing care interventions required, and envisions positive outcomes. Through collaboration with various healthcare professionals and tailored interventions, Arthur’s holistic well-being can be enhanced, and he can achieve optimal health outcomes. This approach emphasizes the importance of a multidisciplinary approach in providing patient-centered care.