Clinical Practice

Topics: Nursing, Nurse, Nursing care plan Pages: 11 (3627 words) Published: November 3, 2013
My Case Study

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The aim of this assignment is to provide a comprehensive individualised patient assessment, identify three patient problems and needs and outline the goals formulated as a result of the assessment. The assessment was guided by the Roper, Logen and Tierney Model of nursing ( Roper et al. 1990).

Patient Profile
My preceptor and I decided on a suitable candidate for this assignment. Consent was obtained from the patient and an appropriate pseudonym (Mary) was decided for the patient that would ensure her identity is protected. Mary was a 79 year old lady who lived alone in the city with excellent family support. She is a widow for 7 years and had two sons and one daughter. Mary was a well dressed lady of five foot inches tall and weighed 56 kg. On arrival to the ward she was accompanied by her daughter. Mary was well spoken and had a hearing aid in each ear but communicated well. Mary has a medical history of Breast cancer and hypertension. Her familial history is also cancer and cardiovascular disease. Mary presented to the emergency department with lower groin pain following a fall at home. Mary said she felt weak after using the toilet, just before she fell and she had complained of diarrhoea for the past couple of weeks. In the emergency department they took a stool sample and it was clear to be malena due to the test results back from the lab.

Nursing Assessment
The comprehensive assessment was conducted utilizing the “12 Activities of Living” (Roper et al. 1990) framework, the activities are detailed below.

The application of this model to the assessment aids the nurse to structure the interview appropriately. Most aspects of the patient’s life is discussed to determine/highlight any actual or possible problems but the assessment should not be used as a checklist (Siviter, 2008). This model was used as it’s the one in use where the author is working and the author is familiar with it even though a plethora of models exist. The 12 activities are as follows incorporating the author’s care plan underneath each heading.

Maintaining a safe environment:

On arrival to the ward Mary was transported on a trolley and accompanied by a staff nurse and her daughter. She was orientated to time as asked by the nurse and she knew where she was and why she was in the hospital. Her hospital band was checked to ensure the details matched the right person. Mary confirmed her name and date of birth in accordance with the band. According to Holland et al (2003) it is imperative that the nurse identifies any difficulties or problems with the patient maintaining a safe environment. The Medical team advised the nurses to keep Mary on bed rest due to her pelvic pain from a fall a couple of weeks ago and also her weakness, to prevent any other falls. There was lower groin pain sustained from her fall. The brakes were put on her bed and the bed was adjusted to make Mary as comfortable as possible. The call bell was left beside her within easy reach and she was shown how to use it and encouraged to press it if there was anything she needed. She was situated in a two bedded ward beside the nurse’s station. She usually ambulated with the help of a walking stick but as she was so weak a nurse had to help her as well as her walking aid. On admission a Falls Risk Assessment (Health Service Executive, 2008), was carried out on Mary. This is an assessment that considers previous injury, frequency, impact etc. Mary was a minor risk candidate due to her recently falling (in the past three months), her age, her visibility, the new environment in the hospital and also due to her fatigue from her loss of blood and fluids through the malena. This was documented in her nursing notes and all staff became aware of her risk and also a risk of falls sign was placed above her bed. This sign is an orange triangle.


Robinson, 2002 explains communication plays a vital part...

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