This portfolio entry requires an assessment and care plan to be presented incorporating the nursing process based on a client that I assisted in the care of during my clinical placement. The patient on which the care plan will be assessed will be a 72 year old female, May Watters who I assisted in the care of during clinical placement in the Emergency Department (ED). May Watters is a pseudo name to ensure confidentiality to An Bord Analtrais standards (ABA 2000). May was brought in by ambulance which was called by her husband Jimmy. May was brought into the ED for Diarrhoea and Vomiting 5/7 days and generally unwell and weakness and non productive cough. Mays’ husband who is her next of kin was concerned about her deterioration over the days previous to admission and called an ambulance to bring her into hospital. Her medical history includes having asthma from a young age, for which she takes a Ventolin inhaler twice daily. Her social history is she smokes ten cigarettes a day and consumes ten units of alcohol a week. She lives at home with her husband. Mays’ husband said that she has not been eating well for two weeks and feels she has lost weight. Immediate assessment of Airway, Breathing and Circulation was carried out and the nursing diagnosis was that the patient had shortness of breath with Spo2 levels of 89% and cyanosis in the mucous membranes. My preceptor decided that it was important to give the patient high flow oxygen in a non rebreathable mask immidiatly to maintain saturation and assess the patients breathing until a doctor could be consulted.
Once the Airway Breathing and Circulation had been addressed the nursing assessment could begin as a full assessment cannot begin until the patients initial needs are met (Brooker et al 2003). The model that was used to plan Mays care was The Activities of Living Model (Roper et al 2006). Assessment is crucial to the nursing process to plan interventions for patients care (Brooker et al 2003). To provide an individualised care plan for May nurses should vary the importance of the the activities of daily living (ADL’s) according to the need of the patient. The patient was admitted to ED while awaiting a medical isolation bed when the medical team decided to admit May and her care plans were started. The care plans that were started for May were one’s appropriate to her condition and problems she had at the time of admission including Breathing, Eating and Drinking, Eliminating, Communicating and controlling body temperature.
Signed: ___________________ (Preceptor) Signed: ___________________(Student Nurse) Part B
A nursing model may be described as a representation of nursing care based on a theory of what nursing care is. It acts as a guide to nurses in assessment, planning and implementation of care to meet the needs of clients and provide a distinct framework on which practice may be based (Brooker et al 2003, Pearson et al 2005). There are many models used in contemporary nursing in all contexts of practice and are seen as continuing to shape nursing as a profession (Cherry et al 2002, Basford et al 2003). They may be viewed as giving nursing a specific identity in this way; by attempting to remove the traditional approach to the delivery of care in nursing with concepts such as physical care, routinism and focusing on the cure of the illness (Pearsons et al 2005). It allows the nurse to care for the individual needs of their client and what is important to them rather than focusing on the illness (Roper et al 2001). Therefore it may be viewed as allowing individualised patient care to be carried out, a core concept in ABA’s code of conduct (2000).
The Roper Logan Tierney (RLT) Activities of living (AL) model is the only model developed in the UK and is widely used. It will be used in this portfolio entry as it is the model used in the assigned areas of clinical placement and is one I am most familiar with. In practice and in reading the...