Nursing Care Study

Topics: Nursing, Nursing care plan, Bedsore Pages: 11 (1942 words) Published: October 14, 2011
Nursing care study

In this assignment I will document and reflect on the care that I gave to one of the patients I

was looking after while on clinical placement. I will be referring to the patient as ‘Mr x’

for confidentiality reasons. ‘Mr x’ was 69 years old. He initially presented with left sided

unilateral weakness, expressive and receptive dysphasia, slurred speech and he suffered from

nocturnal incontinence. He had been transferred from A&E to the ward. He had a provisional

diagnosis of a right middle cerebral artery (MCA) infarct. A CT brain was performed which

showed loss of grey and white matter differentiation and acute infarct in the right middle

cerebral artery territory. He was assessed under the Roper, Logan and Tierney model of

nursing. ‘Mr x’ required full nursing care. This focused on his 12 activities of daily

living. The care he received was planned and based on this assessment. As discussed by

Heath (1998) activities of daily living scales usually focus on basic activities such as eating

and washing. This assessment highlighted areas of care that ‘Mr x’ required assistance

with. As highlighted by Kozier et al. (2008) each activity is linked closely with either

biological, social or psychological needs required for health. It enabled needs and strengths to

be identified. According to Heath (1998) there may be times when older people are unable to

express or make choices, and it is important that nurses facilitate that persons control as much

as possible. He needed complete assistance with all of his activities of daily living. He was nil

by mouth and had a peg tube inserted. I flushed his peg tube with sterile water every four

hours to prevent it from becoming blocked. The peg was inserted as a direct result of his

current health condition. He was unable to swallow and he was at high risk of aspiration on

oral intake. Speech and language assessed his swallow reflex. Regular oral care was

performed due to the fact that he was nil by mouth. All of the patients medication was

administered via the peg tube. I flushed the tube with sterile water after the medication had

been administered to prevent it from becoming blocked. He had a urinary catheter in situ. The

bag from the catheter had to be emptied everyday so that we could record his urinary output.

The patient was on input and output monitoring and I was involved in documenting this.

Everything administered throughout the day via the peg tube was recorded. He was doubly

incontinent and he had a pad in situ. ‘Mr x’ had problems communicating due to

dysphasia. He received full assistance with his personal hygiene. He was charted for

combivent nebs PRN as he occasionally experienced respiratory distress. A care plan on

breathing was developed. (See appendix) Combivent nebs are effective in cases of

respiratory distress as they dilate the bronchioles in the lungs and increase the surface area for

gas exchange. The care given to ‘Mr x’ was evaluated under the patients nursing notes.

Health concerns were identified as a result of assessing the patient under the Roper, Logan

and Tierney model of nursing. ‘Mr x’ had a waterlow score of 15 therefore he was at risk

of pressure ulcer development. A pressure ulcer prevention and immobility care plan were

developed. (See appendix) Pressure ulcers can develop within a matter of hours therefore

pressure ulcer care needs to be performed regularly. As mentioned by Walsh (2002) one of

the main purposes of setting a goal is to set a standard by which we can measure care. The

short term goal in relation to pressure ulcer care was to minimise known predisposing factors

which lead to the development of pressure ulcers. The long term goal was to try and reduce

‘Mr Smiths’ waterlow score by getting him onto a normal diet and free fluids and by

improving the...
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