This essay will include a case study about a patient nursed with the supervision of a registered nurse during a clinical placement. It will demonstrate the ability to assess and develop a care plan for this patient. For this case study, the patient’s name will be changed to Paul and confidentiality will be kept at all times. The nursing process will be described and used to develop a nursing care plan for the above patient. The setting is an integrated hospital service made up of Older Peoples health which provides services such as assessment, treatment and rehabilitation care for the over 65 years old population.
These services are provided by a team of professional such as nurses, physiotherapists, occupational therapists, speech language therapists, dieticians, and social workers to name a few. They work in collaboration to care for patients who are ill and support them to be as independent as possible (Health Point Corporation, 2013). In order to plan care for a patient it is essential to understand the nursing process as it is a vital part of the care plan (Crisp & Taylor, 2010).Potter and Perry describe the nursing process as systematic way to collect client data, examine and analyse it in order to identify client’s problem so individualised nursing care can be provided. The nursing process consists of five steps: assessment, diagnosis, planning, implementation and evaluation (Crisp & Taylor, 2010). Assessment is the first step in writing a care plan.
It is a meticulous and systematic collection of data (Crisp & Taylor, 2010). For this essay the functional health pattern format from Lewis’s medical surgical will be used to collect client data (Graber O’Brien & Thompson, 2010).Paul is an 81 years old European male who lives alone in a private rest home. He was admitted due to an unwitness fall which he has no recollection of. On admission he was diagnosed with multiple rib fractures on the left side ribs 4,5 6 and on the right 5,6,7, head trauma with scalp swelling, and open wound on the chest and left knee. A rib fracture is a crack or a break of the rib bone.
It can cause a lot of pain during breathing, coughing and movement. Most rib fractures heal on its own and healing require about 6 weeks. However pain relief is essential to help manage pain during this process (WebMD, 2010).Paul was chartered 1g paracetamol which is an analgesic to treat mild pain every four hours, and 5mg oxynorm when needed, an opioid analgesic to manage severe pain. In addition Paul stated that his mobility has decreased due to muscle weakness which has deteriorated in the past 3 months. Paul was diagnosed with type 2 diabetes 50 years ago.
He says that his parents and grandparents had diabetes and that it runs in his family. Paul suffers from left ventricular failure a condition where the left ventricle fails to contract enough to maintain cardiac output and peripheral perfusion.As a result, Pulmonary congestion occurs and edema develop from back pressure of blood in the left ventricle causing breathlessness, dyspnea orthopnea and peripheral constriction(Craft, Gordon, Tiziani, Sue, Mc Cance, Brashrs, Rot, 2011). On admission he had fluid overload and was given frusemide 200mg. Today Paul continues taking frusemide to help eliminate excess water as well as regulate his high blood pressure. He also has a permanent indwelling catheter for neurogenic bladder.
Neurogenic bladder is urinary tract condition where the bladder does not empty properly due to neurological condition.As a result a catheter is inserted via the pubic area to so the bladder can be emptied efficiently (MD guidelines, 2011). Paul doesn’t drink alcohol and is an ex smoker. He enjoys the rest home which he has been living in for more than 10 years.
He has a daughter and a granddaughter which he maintains a good relationship with. While visiting her dad in hospital, she brings unhealthy foods such as biscuits, and chocolate bars. Paul is for Cardiopulmonary resuscitation status and has no known allergies.Paul says that he is confused in regards to his diabetes because things changed so much over the years; he feels that he is healthy and is managing his diabetes well. However, while in hospital his draws were full of chocolate biscuits which he eats between meals, and before going to bed.
As for Paul’s nutritional pattern, he says that he eats prepared meals provided by the rest home. He usually has a good appetite. Sometimes he asks his daughter to bring some snacks. He usually drinks well however while in hospital Paul needed to be reminded to drink during the day.Paul is continent of faeces and usually moves his bowel daily.
He becomes anxious if he does not move his bowel daily. He says that in the rest home if this occurs he is given an enema which he finds helpful. His suprapubic catheter is patent and he passes normal good amount of urine and needs help with emptying his catheter bag. Before the incident Paul says that he was able to perform his activity of daily living ( ADL’s) independently and mobilised with a low walking frame.
While in hospital he finds it difficult to stand up and walk for a long period of time. He needs assistance to go to the toilet and shower.He also needs help with setting up for showering. Paul spends lots of time in bed an sitting up in a chair as he is unable to mobilise independently. Paul is aware that his mobility has decreased and he recognises that he needs to do something about it.
Paul has a good self esteem however since the incident, as he is unable to carry out his ADL’s or mobilise, this has caused him to be anxious about returning to the rest home in such condition. Paul says that he usually sleeps well during the night at the rest home, unfortunately while in hospital he states that he has difficulty sleeping.As a result, during the day he becomes tired. Paul lives alone in the rest home. He seems to have a close relationship with his daughter and granddaughter who visit him every day while he was in hospital. He also receives several phone calls from his son who lives in Australia.
During this shift, his vital signs were : Blood pressure,118/62mmhg, heart rate 64 beat per minute, respiration rate is 14 breath per minute, temperature:36. 3 degree Celsius, oxygen saturation 99%. His blood sugar levels (BSL) at 0200 was 16. 3mmol, pre-breakfast, 12.
4, and pre dinner 6. 9, and weight is 80kg.His BSL has being fluctuating between 9- 16 mmol in the past 2 weeks. In February he had a blood test to check the HBA1C level. The result was 65 mmol/mol.
HBA1C levels measures the average blood glucose over the past four to six week. HBA1C . During this shift he has passed 1220ml of urine and moved his bowel which was a formed medium size stool. He was also due for a dressing change. The wound on the chest and the left knee are sloughy in nature.
The slough is yellow colour and appears to be moist with serous exudate. The surrounding of the wound appears to be pink.Paul is alert and orientated to person, place and time. His speech is understandable, he has an intact memory and his mood is appropriate to the situation.
Paul denies chest pain with breathing; however his suffer from dyspnea on exertion which settles at rest. Vital signs are normal. He has a history of depression. He has a scar on his scalp, an open wound on his chest and left knee which Paul denies pain.
His skin is cold and dry. Paul has history of glaucoma and wear glasses and denies any pain related to eyes. Paul does not wear hearing aids however he has total hearing loss in the left ear.Paul denied trouble swallowing. Paul has full dentures and a history of seasonal allergies. Radial pulse is strong.
Paul denies any chest pain. He has regular rate and rhythm with no Edema. Respiration is unlabored. Paul reports no cough. He is on regular diet and moves his bowel daily .
He has a suprapubic catheter which is patent. Catheter bag was emptied numerous times, and output was 1220ml for the duration of this shift. Urine was clear, yellow, and odourless. He has an unsteady gait, due to decreased mobility in the past three months. Paul uses a low walking frame for walking.
Integrity versus despair is the final stage of psychosocial development from 65 years to death which is ego integrity versus despair. In regards to Paul he feels that he has accomplished a happy life despite the difficulties he encountered. He feels happy about his children especially his daughter to whom he has a really good relationship with. Based on the assessment done earlier a nursing diagnosis, a patient outcome or goal, nurse’s interventions, and evaluation of the care provided can be formulated. A nursing diagnosis is a clinical judgment about actual or potential problems a patient may be facing (Crisp & Taylor, 2010).
The first priority nursing diagnosis for Paul is impaired skin integrity related to impaired physical mobility as stated by Paul “my mobility has decreased in the past three months”, Paul needing assistance to mobilise as manifested by the presence of grade 2 pressure ulcers on his sacral area. Pressure ulcers also called decubitus ulcers are injury to the skin or underlying tissue as a result of prolong pressure in combination with shear or friction over a bony prominence. The prolong pressure causes blood vessels occlusion, as a results the tissue is deprived of oxygen and nutrients causing death of the tissue (Craft et al, 2011).Age, lack of mobility, and malnutrition are some risks factors of developing pressure ulcers. Most common areas for pressure ulcer to develop are the sacrum, heel, and elbow (Craft et al, 2011).
The goal for Paul is to experience healing of current pressure ulcers and his skin to be intact with no further pressure ulcers until discharge. The interventions for Paul’s diagnosis will be firstly, to apply cavilon cream twice daily as prescribed. Cavilon cream is a protection barrier cream which provides long lasting protection from body fluids, and moisturises the skin at the same time (Cavilon Durable Barrier Cream, 2013).Applying a permeable adhesive membrane such as cavilon cream promote wound healing (Zaiontz, Lewis, & Yates, 2012). Secondly inspect the current pressure areas daily and document the skin condition.
Regular inspection can provide evidence if the actual treatment is effective or not (Lynn, & Taylor, 2011). Thirdly, encourage Paul to mobilise, as walking and moving increases blood flow and keeps patient out of bed and chair (Crisp & Taylor, 2010). Finally, encourage Paul to lie on his sides when in bed. Alternating position removes pressure from sacral area and allows increase of blood flow (Crisp & Taylor, 2010).Paul’s skin was checked on a daily basis.
Cavilon cream was applied as prescribed. Paul started to sit up more frequently in chair as well as mobilising. On the day of discharge no further pressure ulcers developed. Current pressure ulcers are healing as evidence by the decrease in size.
The goal was achieved. The second nursing diagnosis for Paul will be risk of infection related to skin disruption as manifested by the presence of wounds on his chest, knee and pressure ulcer grade 2 on sacral area. The goal will be that Paul will remain free from symptoms of infection throughout the duration of the week.Infection occurs when a host is invaded by pathogenic organism causing an increase of cytokines and lymphocytes resulting in an increase of body temperature. An open wound is a site of infection (Zaiontz, Lewisk, & Yates, 2012).
The most common cause of infection are nosocomial infection. Clinical manifestations are purulent discharge, redness, fever and elevated white blood cells (WBC) (Crisp, & Taylor, 2010). WBC are cells of the immune system involved in protecting the body against infectious diseases. A normal WBC level range between 4000- 10000 mcL (Pagana & Pagana, 2013).During dressing change signs such as redness surrounding the wound, discharged, elevated temperature would be observed. Monitor elevated WBC at the end of the week.
These are indications of infection (Zaiontz, Lewis, & Yates, 2012). If signs of infections are recognised early prompt treatment can be put in place. Use appropriate aseptic technique before and during Paul’s dressing change. Thorough infection control precautions are essential to prevent infection, specifically with hand hygiene.
Meticulous hand washing before and after dressing change reduces the risk of spread of microorganisms from one area to another (Lynn, & Taylor, 2011).Inform the registered nurse about Paul’s poor eating diet so he can be referred to dietician. Dietician is able to educate patient about the importance of adequate diet and are able to adjust meals in accordance to patient nutritional preference. Meanwhile, a brief education is given to Paul about the importance of adequate nutrition as well as encouragement for Paul to eat his meals. Calories and proteins are needed to meet the metabolic needs and to promote wound healing.
Fluid also prevents dehydration and promotes blood perfusion (Brown & Edwards, 2012).People with diabetes often have decrease blood flow to the extremities. As a result, the body is less able to mobilize normal immune defences and nutrients that promote the body's ability to fight infection and promote healing (Dunning, 2009). Paul was monitored throughout multiple shifts during the week, for signs of infection. Aseptic and hand washing technique were performed at each dressing change.
Paul was assessed by the dietician. At the end of the week Paul was free of sign of infection his temperature was 36. 2degree celcius. The Doctor did not order a WBC at the end of the week.
There was no purulent discharge, or redness from the wound. The goal was met. Although there was no presence of infection at the end of the week, Paul was still monitored for signs of infections and aseptic and hand washing methods were maintained. Knowledge deficit related to dietary regimen as manifested by repeated hyperglycaemic attack between 9 to 15 mmol/L and a HBA1C of 65 mmol/mol. Paul’s glucose level will return to a normal level by the end of the shift; he will understand the importance of healthy eating, his knowledge about healthy nutrition will increase by the end of the shift.A long term goal for Paul would be for him to feel like he has continuous community support in regards to managing his condition with his diet.
Diabetes is a condition where the pancreas is unable to produce insulin; produce little insulin or the cells become resistant to insulin. Insulin is a protein that regulates the amount of glucose in the blood. Without insulin, glucose is unable to enter the cell causing an increase in blood glucose level (hyperglaecemia)( Craft et al, 2011). Clinical manifestations are polyuria, polydipsia, and polyphagia.Complications of diabetes are macrovascular diseases such as coronary artery disease (CAD), stroke, hypertension and microvascular diseases such as neuropathy, retinopathy nephropathy (Robbins, Shaw, Lewis, ; Davis, 2010).
To manage his glucose levels Paul is prescribed actrapid 70/30 a short acting insulin. The intervention for Paul is to administer insulin as prescribed as it will regulate his glucose level and prevent him from developing ketoacidosis and further microvascular and macrovascular damage (Robbins et al, 2010). Assess Paul’s readiness to learn as learning is most effective when patient is motivated (Dunning, 2009).Asses Paul’s level of knowledge in regards to nutrition. This will give an idea where his knowledge gap is so that appropriate interventions can be put in place. As mention in the assessment, Paul has a habit of snacking between meals which usually consist of biscuits and chocolate.
Therefore, in order for his blood glucose level to be managed, offering Paul brief advice during nursing cares on the effect of his unhealthy habits and how it affects him is necessary. Study shows that brief advice is more effective than a long teaching session (Mitchell, 2008).Inform the registered nurse (RN) about Paul’s diet gap knowledge deficiency so she can refer him to a dietician instructing her of where the knowledge gap exists. Dietician can assess Paul’s current diet habits and organise a personalised menu for him. By doing this, there is a better chance that Paul will adhere to his new nutritional plan.
As Paul is already under the care of the diabetes nurse, the registered nurse will inform her about his unmanaged blood glucose level in relation with his diet so she can work in collaboration with the dietician to help Paul.Another intervention will be to encourage Paul’s daughter to accompany him to see the diabetes nurse and the dietician so she could learn about diabetes, healthy eating choices which will help manage Paul’s diabetes (Diabetes New Zealand, 2008). Insulin was administered as chartered. Paul’s glucose level was managed during the entire shift as evidenced by blood sugar level readings being below 9mmol/mol. Brief advice was given however Paul was unwilling to cut down on his sugary treats.
This also means that Paul is not ready to receive any further dietary education.Ongoing assessment of Paul readiness will be continued while in hospital. Paul will be referred to the diabetes nurse and a dietician once discharged. Conclusion The nursing process has four stages: assessment, diagnosis, planning, implementation, and evaluation. It is an essential tool to provide a personalised care for a patient.
A comprehensive assessment was use to collect information from Paul. From there a personalised care plan consisting of three nursing diagnosis with goals and interventions were formulated. Although not all of Paul’s goals were achieved he has made progress towards achieving better health.Referenceshttp://www.mdguidelines.com/neurogenic-bladderhttp://www.diabetes.org.nz/food_and_nutrition/healthy_food_choices__and__tipshttp://www.healthpoint.co.nz/specialists/older-peoples-health/auckland-dhb-a-links-older-peoples-health/at/auckland-city-hospital/http://www.webmd.com/a-to-z-guides/fractured-rib-topic-overview
