Sample Nursing Care Study

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,
As highlighted by Roper, Logan and Tierney (2004) the most important nursing

activity in the prevention of pressure sores is the relief of pressure and minor changes of

position should be incorporated into the nursing care plan as well as the familiar intervention

of regular turning. According to Kozier et al. (2004) the client should be assisted to be as

mobile as possible as activity enhances circulation. He was nursed on a pressure relieving

mattress. Jackson (2003) stated that it is appropriate for patients to be nursed on an

alternating pressure overlay or mattress, which ensures that no part of their skin is subjected

to constant pressure. Pillows were placed under the patients heals, behind his legs and

underneath his buttock. Roper, Logan and Tierney (2004) argued that careful positioning and

intelligent use of pillows can help to minimise tissue compression. It was important that ‘Mr

Smith’ was commenced on a normal diet as this would lower his waterlow score. Both the

staff nurse and I worked closely with the dietician. As highlighted by Roper, Logan and

Tierney (2004) the nurse often works in collaboration with other professionals to assist
There were both short and long term

goals in place for this health concern. The short term goal in relation to oral care was to

maintain a good standard of oral hygiene. The long term goal was to get ‘Mr x’

tolerating a normal diet so that he would not require regular oral care. There were planned

nursing interventions put in place in relation to oral care. ‘Mr x’ received oral care every

hour. According to Thurgood (1994 cited in Randall 2000) restricted oral intake such as ‘nil

by mouth’ can result in dehydration and dry mouth. A soft toothbrush and toothpaste was

used. Thurgood (1994 cited in Randall 2009) emphasises the fact that a soft bristled

toothbrush is the most effective agent for removing plaque and debris from the mouth, teeth

and tongue. The patient was unable to swallow and there was a risk of aspiration so we used

suctioning. As discussed by Jones (1998 cited in Randall 2009) suction can be used to

remove excess fluid from the mouth if the patient is unconscious or if they have a problem

with swallowing as it is essential to prevent choking or aspiration of fluid. According