Care Plan Based on Activities of Daily Living Model
Part A
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
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