This essay will include a case study about a patient nursed with the supervision of a registered nurse during a clinical placement. It will demonstrate the ability to assess and develop a care plan for this patient. For this case study, the patient’s name will be changed to Paul and confidentiality will be kept at all times. The nursing process will be described and used to develop a nursing care plan for the above patient.
The setting is an integrated hospital service made up of Older Peoples health which provides services such as assessment, treatment and rehabilitation care for the over 65 years old population. These services are provided by a team of professional such as nurses, physiotherapists, occupational therapists, speech language therapists, dieticians, and social workers to name a few. They work in collaboration to care for patients who are ill and support them to be as independent as possible (Health Point Corporation, 2013).
In order to plan care for a patient it is essential to understand the nursing process as it is a vital part of the care plan (Crisp & Taylor, 2010). Potter and Perry describe the nursing process as systematic way to collect client data, examine and analyse it in order to identify client’s problem so individualised nursing care can be provided. The nursing process consists of five steps: assessment, diagnosis, planning, implementation and evaluation (Crisp & Taylor, 2010).
Assessment is the first step in writing a care plan. It is a meticulous and systematic collection of data (Crisp & Taylor, 2010). For this essay the functional health pattern format from Lewis’s medical surgical will be used to collect client data (Graber O’Brien & Thompson, 2010). Paul is an 81 years old European male who lives alone in a private rest home. He was admitted due to an unwitness fall which he has no recollection of. On admission he was diagnosed with multiple rib fractures on the left side ribs 4,5 6 and on the right 5,6,7, head trauma with scalp swelling, and open wound on the chest and left knee. A rib fracture is a crack or a break of the rib bone. It can cause a lot of pain during breathing, coughing and movement. Most rib fractures heal on its own and healing require about 6 weeks. However pain relief is essential to help manage pain during this process (WebMD, 2010). Paul was chartered 1g paracetamol which is an analgesic to treat mild pain every four hours, and 5mg oxynorm when needed, an opioid analgesic to manage severe pain. In addition Paul stated that his mobility has decreased due to muscle weakness which has deteriorated in the past 3 months. Paul was diagnosed with type 2 diabetes 50 years ago. He says that his parents and grandparents had diabetes and that it runs in his family. Paul suffers from left ventricular failure a condition where the left ventricle fails to contract enough to maintain cardiac output and peripheral perfusion. As a result, Pulmonary congestion occurs and edema develop from back pressure of blood in the left ventricle causing breathlessness, dyspnea orthopnea and peripheral constriction(Craft, Gordon, Tiziani, Sue, Mc Cance, Brashrs, Rot, 2011). On admission he had fluid overload and was given frusemide 200mg. Today Paul continues taking frusemide to help eliminate excess water as well as regulate his high blood pressure. He also has a permanent indwelling catheter for neurogenic bladder. Neurogenic bladder is urinary tract condition where the bladder does not empty properly due to neurological condition. As a result a catheter is inserted via the pubic area to so the bladder can be emptied efficiently (MD guidelines, 2011). Paul doesn’t drink alcohol and is an ex smoker. He enjoys the rest home which he has been living in for more than 10 years. He has a daughter and a granddaughter which he maintains a good relationship with. While visiting her dad in hospital, she brings unhealthy foods such as biscuits, and chocolate bars....
References: Brown, D. & Edwards, H. (2012). Lewis’s medical-surgical nursing: assessment and management of clinical problems (3rd ed). Sydney: Elsevier Mosby.
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