NURBN2000 Transition To Nursing Studies
Questions:
2. Identify 4 major issues for Kevin Jones, his social history and provide a summary of your overall assessment of him. Ensure that you use ‘objective’ language. This would be similar to what you would write in nursing notes as an admission history.
3. Using the Nursing diagnosis section, select the three health nursing diagnosis that you think are a priority for Kevin and include the evidence from your assessment that supports this.
4. Now prioritise these 3 important nursing problems to formulate a nursing care plan for Kevin.
5. Develop a nursing care plan with rationale (referenced) and related interventions that could be implemented for Kevin.
6. Complete the evaluation sections of the care plan – identify ways that you could measure success in relation to each of these interventions.
Answers:
Introduction
In Assessment you are required to complete a comprehensive health assessment and nursing care plan on information given to you in the case study- Mr. Kevin Jones. The case study information is located in the Book – Case Study Guidelines for Assessment.
Using the information gathered from the case study of Mr. Kevin Jones, you are expected to document the assessment you have undertaken. You are also asked to identify four (4) priority issues, develop, implement and evaluate your nursing care plan for Mr. Kevin Jones. All information is to be recorded in this Health Assessment & Nursing Care Plan Workbook. Your completed Health Assessment & Nursing Care Plan.
Guidelines for Health Assessment and Nursing Care plan
- This assessment relies on students being familiar with the nursing process as you will be required to follow the steps outlined in this process. If you are not familiar with this, review in any recommended nursing textbook – however, this has been covered in your prior EN training.
- Complete the workbook, ensuring you have answered all the questions
- Students will demonstrate clinical decision making skills in:
- The Nursing Process.
- Identification/ assessment of nursing problems (nursing diagnosis)
- Planning and Implementation of nursing care
- Documentation of nursing data.
- Evaluation of nursing care
The present case study focuses on the condition of a patient named Kevin who had been a 75 year old man who had gone through a cardiovascular accident or stroke which resulted into paralysis. The past history of the patient reveals that he had been paralyzed and had been leaning on one side and forgot where his hand had been in the past which indicates that he had motor coordination deficiency due to the stroke. He also had speech slurring and difficulty in verbalization which also caused immense irritation and agitation in the patient. He also had gait problems and had only started mobilizing with the assistance of three pronged sticks, hence it also can be mentioned that the patient had persistent fall risk. Along with that, the patient had been complaining of a chronic cough with a small amount of discoloured greenish yellow sputum, fever, flushed skin, chills, loss of appetite, taking little fluids, malaise and body aches over the past few days. The vital signs of the patient revealed temperature 38.3, blood pressure 90/60, and respiratory rate as 24 per min, and oxygen saturation 93%. The patient also exhibited crackles & wheezes on auscultation with diminished breath sounds. Along with that he had erratic bowel and incontinent urine as well; hence he is at risk for dehydration as well (Cumming et al., 2013).
Hence the first component of physical health assessment will be the Primary assessment following the ABCDE format where the airway, breathing, circulation, disability and exposure risk of the patient. Here, it has to be mentioned that the patient had been chronic cough and excess production of sputum which can lead to shortness of breath and reduced oxygen saturation in the patient and lead to exacerbation of the pneumonia. Second component of the assessment for the patient will need to focus on specialized secondary assessment focussing o the key issues. For instance the patent had been suffering from weight loss, lack of appetite, taking more fluids, malaise and body aches. The pneumonia infection could have been a contributing factor to the same however the swallowing difficulty could also have contributed to the lack of appetite and subsequent weight loss as well. Lastly, the patient mobility restriction and had trouble with maintaining his balance even after using the three pronged stick; hence, the patient had been under heavy risk of falling which could lead to patient sustaining injuries. Hence, fall risk assessment will be the third physical health assessment component (Abubakar & Isezuo, 2012).
For mental health assessment, it has to be mentioned that a cardiovascular accident has significant impact on altering the mental health of the patient. As the patient had mentioned lack of coordination and the inability to remember where his hands are, the first mental health assessment component will be mini-mental state examination. This will help in identifying the lapse in the cognitive stats of the patient as well. Along with that the mental health assessment with respect to cognitive status of the patient will include Neurobehavioral Cognition Status Exam (NCSE) as well. The second component for the mental health assessment will be the assessment for depression. According to the Bartoli et al. (2013), almost one third of the total stroke patient population suffers from post stroke depression, and the possibilities are even higher for those with any temporary or permanent disability. It has to be mentioned in this context that the patient had been exhibiting signs of frustration and emotional outbursts as well. Along with that he had been anxious about returning home and seemed to be fretting about his home, land and animals. The patient had admitted that he often does not like taking or anyone, barely speaks to his staff and got agitated and irritable with the nurses, physiotherapists, cleaners as well during his stay in the hospital. The patient seemed to be ruminating about his past and his wife who had died 13 years ago. Hence the patient had been showing all signs of depression and needed a depression assessment using either Beck Depression Inventory or Hamilton Rating Scale for Depression (Lincoln et al., 2013).
(a) Identify 4 Key Health Issues/ problems for nursing care
- – Pneumonia
- – Dehydration
- – Depression
- – Fall risk
(b) Document Kevin’s social history
Social history of the psychosocial contextual factors of a particular individual has a significant impact on the health and wellbeing of patient and can play a profound role in the recovery statistics of the patient as well. For the case study that has been selected for the assignment, the patient Kevin had been a 75 year old man with three children, two of whom live outside of Victoria, his native land. However, one of his sons lives nearby although he cannot give enough time to his father due to his busy schedules. The patient had suffered from a stroke recently which had rendered him partially paralysed and not able to successfully complete his activities of daily living. It has to be mentioned that his financial abilities are limited and he desperately has wished to go back to his house and manage things on his own due to his need for empowerment and independence. He lives in an old farm which had not been renovated for 30 years and he has access to bare minimal necessities in the old farm that he had been living in.
(c) Summary of overall assessment for Kevin
Summarizing the entire assessment program it has to be mentioned that the nursing care priorities for the patient needs to be identified. It has to be mentioned in this context that the patent had been suffering from a number of large number of medical concerns. However the physical and mental health assessment had helped in the sorting of the most pressing care needs and focusing on the care priorities of the patient. The first and foremost care priority for the patient the present condition is the lower lobe pneumonia. Along with that, the physical health assessment also discovered that the patient had been suffering from dehydration and fall risk. And hence, Kevin will require care strategies focused on addressing the above mentioned care priorities. For the mental health assessment it was discovered that his cognitive health had not been much deteriorated however he had been showing signs of prominent post stroke depression. Hence the fourth care priority will be the depression.
Identifying Nursing Problems (Diagnosis)
Nursing Diagnosis
A nursing diagnosis is a statement that describes the PERSON’S actual or potential response to a health problem that requires nursing care. It is a three part statement with diagnosis, cause and evidence.
Based on Assessment data you have gathered, select the three priority diagnoses that you feel are the most appropriate for Kevin.
Ensure you include what evidence you have to support this.
Lower lobe pneumonia
Evidenced by:
The chest X-ray of the patient revealed the presence of lower lobe pneumonia. And along with that he patent had been exhibiting consistent chronic coughs, wheezing and crackles, along with shortness of breath and discoloration of the sputum. The primary respiratory assessment discovered that the patent had ineffective breathing pattern and airway obstruction as well.
(2) Dehydration
Evidenced by: The patient had erratic hard bowels and incontinence in urinary movement. Along with that that patent had admitted to be drinking very little water or any other fluids. The physical health assessment also discovered fluid volume deficiency leading to dry and flushed skin.
(3) depression
Evidenced by: Low mood, irritability, emotional outbursts, not talking to the rest of the staff and reminiscing his time with his decreased wife
Nursing Care Plan1
To develop the Nursing Care Plan:
- Critically analyse, cluster and validate your assessment data for Kevin into the following format:-
- Include three(3) nursing problems diagnosis with Goals (outcomes), Nursing Interventions, Rationales (reasons)
- Write clear statements that clearly reflect the problem. You may use your own wording.
- You may use the health patterns cluster statements below to assist you identify a nursing diagnosis, or you may use ones that reflect the individual client.
Goals or expected outcomes
Have a time frame and are realistic outcomes related to the nursing diagnosis.
Interventions
Are the nursing actions needed to achieve the goal?
Rationale
The reasons for nursing interventions are recorded in detail.
Evaluation
Determines if nursing interventions are effective and goals have been achieved.
Evaluation consists of:
- Collection of data related to outcomes
- Comparison of this data with predicted outcomes
- Revision of nursing actions to goals and or outcomes
- Drawing conclusions about problem status and then continuing, modifying or terminating the care plan
- Documenting changes in nursing interventions and outcom
Now continue to the Nursing Care Plan below and enter your dat
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Nursing diagnosis: 1 (Nursing Problem) |
Lower lobe pneumonia |
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Evidenced by |
Chest Xray, chronic cough, Wheezing and crackles, diminished breathing sounds. |
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Goal & time frame
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The patient will be given antibiotic therapy and better airway management which will help the patient overcome the risks for pneumonia effectively. The patient will be free from pneumonia within 2 to 3 weeks. |
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Nursing Interventions. (actions to address the problem) |
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Write nursing interventions here The nursing interventions that will be given to the patients includes: · auscultation of the breathing sounds and airway management of the patient · providing external oxygen therapy to the patient to help him overcome the shortness of breathing (Klompas et al., 2014) · performing airway suction to clear the airways · administering bronchodilators such as · administration of antibiotics · changing the posture of the patent to the low fowlers position · helping the patient with breathing exercises |
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Rationale: According to the Diaz et al. (2013), auscultation of the breathing sounds will help in discovering the exact breathing abilities and be able to apply interventions. The Oxygen therapy will help in elevating the immediate risk of the patient of acute dyspnea. According to the Beltrão et al. (2015), the airway cleaning helps in improving the breathing capabilities twice as effectively and also actively increases the oxygen saturation. The bronchodilation effect will reduce the frequency and severity of the bronchospasms and reduce the bronchoconstrictions as well. The antibiotic will help in inhabiting the spread of the infection and will help in inhibiting the chances of further exacerbations. The change in posture has been proved to help in improving the respiratory burden and relaxing the patient along with the breathing exercises (Pascoal et al., 2014). |
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Evaluation of Care (how successful were the interventions) The therapies had been quite successful in reducing the frequency shortness of breath and bronchospasms, the medication given to the patient had been successful in reducing the coughing and the consistency of the sputum and inhibiting the spread of the infection. Along with that, the airway clearance and breathing exercises helped reduce the respiratory rate of the patient within the normal rates and along with that calming the patient. |
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Nursing diagnosis: 2 (Nursing Problem) |
Dehydration |
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Evidenced by |
Lack of fluid volume equilibrium in the body, decreased water or fluid intake, incontinence and hardening of stool and changes in urine consistency.
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Goal & time frame
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The patient will be given the dehydration bundle and he will be well hydrated within 24-48 hours. The skin texture and integrity will improve as well and the patient will appear visibly better. |
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Nursing Interventions (actions to address the problem) |
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Write nursing interventions here The nursing interventions in this case will be: · Monitoring the vital signs of the patient including the blood pressure and heart. · Assessing the skin texture and the mucous membranes for the signs of dehydration (Miller,2017) · assessing the colour, consistency and amount of the urine · monitoring and documenting the temperature · Encouraging the patient to take more fluids and monitoring the serum electrolyte levels (Li et al., 2014). |
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Rationale: Decrease in the blood volume can cause hypotension and cardiac output reduction. Dehydration causes loss of skin elasticity and detects alarmity in case of fluid volume deficiency (Li et al., 2014). Urinary output lesser than 30ml/ hour and concentration of urine helped detecting severity of the dehydration. Febrile states decrease body fluids by perspiration and increased respiration, it helped in tracking whether here is any insensible water loss. Serum electrolyte deficit is efficient indicator of dehydration and it helped in improving the hydration state of the patient (Castellan et al., 2016). |
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Evaluation of Care The interventions helped in better understanding of the condition of Kevin and helped improve his dehydration status. The elaborate assessment helped in better discovery of the exact severity of the dehydration and encouragement to take more fluids and electrolyte therapy helped in reviving his hydration state within roughly 48-52 hours. The urinary and bowel issues also improved gradually with improved hydration state |
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Nursing diagnosis: 3 (Nursing Problem) |
Fall risk |
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Evidenced by |
Unstable gait, leaning on left side, not being able to locate his right hand, lack of motor coordination skills . |
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Goal & time frame |
The patient will be free from the fall risk while his stay in the health care facility. This care goal will be for as long as the patient stays in the facility. |
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Nursing Interventions (actions to address the problem) |
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Write nursing interventions here The interventions in this case will be: · performing a thorough fall risk assessment for the patient · performing an assessment for checking the disability status of the patient · decluttering the physical environment of the patient (Costa-Dias et al., 2014) · making the patient wear non skid footwear and position bed rails to reduce risk of falling · provide the patient with assistive devices for walking necessary and placing the call light within his reach · increasing the luminosity of the room Kevin is staying in (Castellan et al., 2016) |
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Rationale: The fall risk assessment helped in discovering the exact contributing factors in this case and the address those care needs. The decluttering, increased luminosity and protective bed rails helped in reducing the fall risk effectively (Castellan et al., 2016). The non skid footwear and the assistive walking aid helped in further reducing the risk of falling. According to the Costa-Dias et al. (2014), placing the call light and other necessary stuff within the reach of the patient can help in reducing the fall risk of the patient. |
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Evaluation of Care The interventions had been successful in reducing he fall risk of the patient effectively and along with that the patient had been able to verbalize his needs effectively using the call light and had been devoid of any risk to fall and injury throughout his stay in the facility. |
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References
Abubakar, S. A., & Isezuo, S. A. (2012). Health related quality of life of stroke survivors: experience of a stroke unit. International journal of biomedical science: IJBS, 8(3), 183.
Bartoli, F., Lillia, N., Lax, A., Crocamo, C., Mantero, V., Carrà, G., … & Clerici, M. (2013). Depression after stroke and risk of mortality: a systematic review and meta-analysis. Stroke research and treatment, 2013.
Beltrão, B. A., Herdman, T. H., Pascoal, L. M., Chaves, D. B. R., Silva, V. M., & Lopes, M. V. (2015). Ineffective breathing pattern in children and adolescents with congenital heart disease: accuracy of defining characteristics. Journal of clinical nursing, 24(17-18), 2505-2513.
Castellan, C., Sluga, S., Spina, E., & Sanson, G. (2016). Nursing diagnoses, outcomes and interventions as measures of patient complexity and nursing care requirement in Intensive Care Unit. Journal of advanced nursing, 72(6), 1273-1286
Castellan, C., Sluga, S., Spina, E., & Sanson, G. (2016). Nursing diagnoses, outcomes and interventions as measures of patient complexity and nursing care requirement in Intensive Care Unit. Journal of advanced nursing, 72(6), 1273-1286.
Costa-Dias, M. J., Oliveira, A. S., Martins, T., Araújo, F., Santos, A. S., Moreira, C. N., & José, H. (2014). Medication fall risk in old hospitalized patients: a retrospective study. Nurse education today, 34(2), 171-176.
Cumming, T. B., Churilov, L., Lindén, T., & Bernhardt, J. (2013). Montreal Cognitive Assessment and Mini–Mental State Examination are both valid cognitive tools in stroke. Acta Neurologica Scandinavica, 128(2), 122-129.
Davidson, P., & Everett, B. (2015). Managing approaches to nursing care delivery. Transitions in nursing: preparing for professional practice. Chatswood, New South Wales, Australia: Elsevier Health Sciences, 125-142
Diaz, T., George, A. S., Rao, S. R., Bangura, P. S., Baimba, J. B., McMahon, S. A., & Kabano, A. (2013). Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey. BMC public health, 13(1), 157.
Klompas, M., Branson, R., Eichenwald, E. C., Greene, L. R., Howell, M. D., Lee, G., … & Yokoe, D. S. (2014). Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(S2), S133-S154.
Li, Y., He, R., Ying, X., & Hahn, R. G. (2014). Dehydration, hemodynamics and fluid volume optimization after induction of general anesthesia. Clinics, 69(12), 809-816.
Lincoln, N. B., Brinkmann, N., Cunningham, S., Dejaeger, E., De Weerdt, W., Jenni, W., … & De Wit, L. (2013). Anxiety and depression after stroke: a 5 year follow-up. Disability and rehabilitation, 35(2), 140-145.
Miller, C. G. (2017). Dehydration in Nursing Home Residents: A meta-analysis of causes of dehydration, implications, and those most at risk
Pascoal, L. M., Lopes, M. V. D. O., da Silva, V. M., Beltrão, B. A., Chaves, D. B. R., de Santiago, J. M. V., & Herdman, T. H. (2014). Ineffective breathing pattern: defining characteristics in children with acute respiratory infection. International journal of nursing knowledge, 25(1), 54-61.
Pata, R. W., Lord, K., & Lamb, J. (2014). The effect of Pilates based exercise on mobility, postural stability, and balance in order to decrease fall risk in older adults. Journal of bodywork and movement therapies, 18(3), 361-367.
Wagg, A., Gibson, W., Ostaszkiewicz, J., Johnson, T., Markland, A., Palmer, M. H., … & Kirschner?Hermanns, R. (2015). Urinary incontinence in frail elderly persons: Report from the 5th International Consultation on Incontinence. Neurourology and urodynamics, 34(5), 398-406.
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