Take patients medical history. Assess Bobby for signs of injury after fall (cuts, scrapes, bruising) wound assessment, assess vital signs, assess if patient is dazed, confused, showing signs of weakness, pain or distress, assess pain scale, skin integrity (color, warmth), review falls risk status, conduct visual assessment, assess medications, assess patients environment for factors known to increase fall risk. Observe movements/gait, assess if any objective symptoms are present to indicate lack of stability. How does Bobby look Is he well groomed Things to note include appearance, hygiene, clothes and concern of appearance.Emotional- Conduct behavior assessment, mental health and cognitive screening.
Assess patients access to emotional support services. Inform patient of mental health services available to him. Assess emotional state.Social- Ask patient about family/partner or carer.
Is patient involved in any social activities or groups within the community What is his home environment/relationships like How does patient socialize (online, phone or face to face) Does patient have any hobbies/interests Is Bobby employedReligion- Ask patient if he is religious/spiritual person RN needs to be supportive of beliefs/practices and ensure patient has access availability to spiritual/religious resources, and visits from spiritual groups.Cultural- Provide access for cultural practices, ascertain dietary requirements. Identify significant cultural celebrations for inclusion of activities. Does patient speak english If not does he require an interpreter Observe verbal/non-verbal cues and verify significance of these behaviors in relation to nurse-patient interaction.Development- Perform cognitive screening to determine cognitive and psychosocial development. Assess perception, memory, and thinking (the processes by which a person perceives, recognizes, registers, stores, and uses information).
Assess vision and hearing. Patients level of education Assess patients adaptation (coping behaviour) ability to handle changes in environment. Assessment data from Case Study 2Nursing Diagnosis Actual and Potential issuesPlan What are your Goals Implementation Nursing actionsEvaluation Physical Ms Williams has difficulty mobilizing this is also causing her distress due to difficulty in breathing.Exertional dyspnea related to imbalance between oxygen supply/demand Risk of anxiety related to breathlessness when mobilizing.
Ms Williams has the ability to perform required activities of daily living. Patient will be able to take care of hygiene needs free of respiratory distress. Patient maintains an effective breathing pattern. Patient verbalises ability to breathe comfortably without sensation of dyspnoea.
Improved ability to walk without symptoms. Patient describes own anxiety and coping patterns. Patient has vital signs that reflect baseline or decreased sympathetic stimulation. Assist to focus on what patient can do, rather than on deficits. Vital Signs Monitoring.Monitor blood pressure, pulse, temperature, and respiratory status, as appropriate. Arrange for use of oxygen devices that facilitate mobility and teach patient accordingly.
Teach adaptive breathing techniques such as deep breathing exercises. Monitor emotional, physical, social, and spiritual response to activity. Daily evaluation of vital signs (temperature, O2 saturation, respirations, blood pressure, pulse rate) and conduct respiratory assessment (inspection, palpation, percussion and auscultation). Evaluate level of activity tolerance. Monitor Ms. Williams mood and anxiety levels.
Monitor for increased restlessness, anxiety, and air hunger. Assess physical reactions to anxiety. Physical Ms Williams has hypertension (high blood pressure).
Altered cardiac output related to ineffective tissue perfusion. Patient demonstrates adequate cardiac output as evidenced by HYPERLINK https//nurseslabs.com/cardiovascular-system-anatomy-physiology/ t _self blood pressureand HYPERLINK https//nurseslabs.com/cardiovascular-system-anatomy-physiology/ t _self pulse rateand rhythm within normal parameters for patient strong peripheral pulses and an ability to tolerate activity without symptoms of dyspnoea. Patient describes strategies for managing hypertension.
Patients blood pressure and pulse will remain within acceptable limits. Encourage physical mobility, daily exercise as tolerated.Relaxation techniques taught to combat stress. Incorporate low-sodium diet. Assess for signs and symptoms of hypertensive episodes, angina, shortness of breath, decreased urinary output, headache, visual changes. Provide medication(s) as ordered and monitor for side effects, effectiveness.
Educate patient about condition and incorporate lifestyle changes.Assess skin color and temperature daily. Assess heart rate and blood pressure daily.
Note respiratory rate, rhythm and breath sounds daily.Physical Ms Williams has swelling in lower legs (peripheral oedema).Effusion of fluid into extracellular space related to compromised regulatory system. Potential risk for skin tears related due to aging, fragile skin and impaired mobility.
Patient will have a reduction or elimination of pain and inflammation in lower extremities. Patient will have adequate interventions in place to minimize risk for skin tears. Patient demonstrates use of adaptive techniques that promote ambulation and transferring.
Check swelling. Measure size. Ensure area is free of redness, purulent discharge, tightness, pitting and pain. Elevate oedematous extremities, and handle with care. Monitor input and output of fluids closely. Encourage good nutrition and hydration to promote healthier skin. If skin tear occurs, treat per facility protocol and notify MD.
Note changes ofoedema by palpating over thelegs, ankles and feet. Assess Ms Williams pain levels A Registered Nurse uses a systematic, dynamic, rather than static way to collect and analyse data about a client, it is the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. A nurses assessment of a patient in pain includes not only the physical causes and manifestations of pain, but the patients response an inability to function normally. Anurseis usually the first person a patient interacts with,nursesare an integral part of the comprehensive standards of health-care andhealthpromotion. The nurse/patient relationship is based on mutual trust and respect, being sensitive to self and others, and assisting the patientsphysical, emotional, and spiritual needs through knowledge and skill of the nursing profession. Nurses learn the nursing process as part of their education.
The nursing process starts with thenursing assessment, which involves collecting information from and about the patient. From that information, the nurse uses nursing judgment to identify what kind of response the patient is experiencing as a result of their health condition or other life process. The terms used to describe this response into a usable summary statement of the problem is thenursing diagnosis. Holistic assessment involves care for the whole person considering all facets of the individual which includes the physical, mental, emotional, spiritual and cultural aspects and not just observing the person as a patient or diagnosis, it forms a strong foundation for the care plan for the individual Kozier Erb (2016). It is a vital step, as the information gathered during the assessment determines the initial phases of nursing care.
The information I have gathered in case study 1 was obtained in order to gain an overall picture of Bobbys current health situation in order to determine the best care plan for him. As a nurse, responding holistically to the needs of the individual is important in drawing meaningful information about various aspects of the patient, and in understanding the patients perspective of their current situation and to plan effective interventions Kozier Erb (2016). Bobby has had a fall therefore physical assessment of pain and wounds and possible causes of the fall are a critical first step in his holistic assessment. Assessment skills are necessary in order for nurses to build relationships with patients, often patients that are admitted into care are in a vulnerable position, by gaining a holistic view of the person we can offer support and comfort to the individual whilst maintaining high standards of professional medical care Kozier Erb (2016). HYPERLINK https//nurseslabs.com/nursing-care-plans/ t _self o Nursing Care Plans List Nursing care planninggoals for Ms Williams in regard to her hypertension includes adherence to a therapeutic regimen, lifestyle modifications, and prevention of complications are the focus of the nursing care for a patient with hypertension Gulanick Myers (2017).
By reviewing clients risk related factors with conditions that stress the heart, assessing factors that may compromise circulation and place excessive demands on the heart is of critical importance Gulanick Myers (2017). It is important to identify contributing factors which can help provide strategies to avoid unnecessary stress on the body. A comparison of pressures provides a more thorough picture of vascular involvement or scope of the problem, therefore assessing the patients physiological responses (blood pressure, heart rate) regularly in response to the stress of activity can help in avoiding overexertion and put in place energy-saving techniques to reduce energy expenditure, thereby assisting in equalization of oxygen supply and demand Gulanick Myers (2017). Implementing dietary sodium restrictions can help in managing fluid retention and with associated hypertensive response, fluid restriction decreases extracellular fluid volume and reduces demands on the heart Gulanick Myers (2017). Ms Williams dyspnoea on exertion is causing her distress to the extent that she is avoiding walking and self-care activities.
By engaging in gradual activity progression, may prevent a sudden increase in cardiac workload and providing assistance when needed may help to encourage movement in performing activities Gulanick Myers (2017). Assisting self-care processes may ease her physical discomfort on exertion. Assessing Ms Williams emotional and psychological factors affecting her current situation can indicate her level of stress/anxiety that may be increasing the effects of her illness as a result of being forced into inactivity from the stress of her dyspnoea Gulanick Myers (2017). An ambulation aid (walker,cane) may offer Ms Williams relief when mobilising and may help increase her independence by helping with balance and stability. Oxygen is also given in some cases to ease dyspnoea on exertion or shortness of breath on exertion and incorporating breathing exercises can help improve air movement in and out of the lungs and is also used as a tool to help ease anxiety Gulanick Myers (2017). Breathing troubles stemming from HYPERLINK https//www.
nps.org.au/medical-info/consumer-info/chronic-obstructive-pulmonary-disease-copd chronic obstructive pulmonary diseasecan improve with special breathing techniques, such as pursed-lip breathing and breathing muscle strengthening exercises. In more severe cases, HYPERLINK https//www.
msdmanuals.com/en-gb/professional/pulmonary-disorders/symptoms-of-pulmonary-disorders/dyspnea t _blank supplemental oxygenwill be needed Gulanick Myers (2017). Ms Williams also has peripheral oedema which is the presence of palpable swelling resulting from increased interstitial fluid in the tissue of the extremities Gulanick Myers (2017).
It is important to protect her swollen legs from additional pressure injury, as injury to the skin due to the swollen area takes longer to heal and is at more risk of infection Gulanick Myers (2017). Ms Williams should elevate her legs with care (as oedematous skin is more susceptible to injury) when sitting down as elevation increases venous return to the heart this can help to decrease oedema Gulanick Myers (2017). Assisting Ms Williams if required, with repositioning every 2 hours can help prevent fluid accumulation in dependent areas.
Daily assessment for skin discolouration, aching tender limbs, stiff joints and areas of skin that temporarily hold the imprint of the finger when pressed (pitting oedema) needs to be done to evaluate the progress or worsening condition of the afflicted limb/s Gulanick Myers (2017). The goal of Ms Williams care plan is to ensure she has no pain or minimal pain and to reduce her stress levels, my aim was to minimize her loss of independence as much as possible, promote health and prevent disability. The use of thenursingprocess is critical in being able to identify thenursing diagnosis and implement specificnursing interventions and evaluatepatientoutcomes that lead to qualitynursing care. A care plan flows from each patients unique list of diagnoses and should be organized for the individuals specific needs. Care plans teach nursing students how to think critically and how to care for patients on a more personal level, not as a disease or diagnosis. References Berman, A , Kozier, B. , Erb, G.
(2016), Kozier and Erbs fundamentals of nursing Concepts, process and practice, Pearson, Melbourne. Gulanick, M., Myers, J.L.
, (2018), Nursing Care Plans Diagnosis, interventions and outcomes, Elsevier, Missouri. Kylie Sallaway Student No. 1103088 NUR116 Task1B PAGE MERGEFORMAT 2 Y, B8L 1(IzZYrH9pd4n(KgVB,lDAeX)Ly5otebW3gpj/gQjZTae9i5j5fE514g7vnO( ,[email protected] /[email protected] 6Q