HLT54115 Diploma In Nursing
Question
Read carefully through the information below about Mr Nigel Wheeler, a new patient on your ward. Study the nursing care plan which has been created for Mr Wheeler – there are some important points missing in this plan. You must fill in the blanks (bullet points&/or numbers) to ensure complete quality care for this patient.
Biography:
Nigel is 86 years of age. Nigel lives in his own home with his wife. Nigel has just been admitted to hospital ashe has had a series of falls over the past few weeks and his Dr wants to investigate why this is happening so frequently in recent months. Nigel is getting increasingly difficult to manage at home as his wife, who is 84 years old, is quite frail and displaying early signs of dementia.
Medical Diagnosis:
Osteoarthritis, falls for investigation, pressure injury, constipation and depression
Care Related Needs:
His mobility is affected by pain associated with his OA. Nigel is only able to ambulate with assistance, which impacts his ability to perform ADL’s. Nigel finds it difficult to get around and becomes exhausted and short of breath.
Question
On the tab Take Action, 5 points need to be filled in.
On the tab Reflect on Process is left blank and needs to be filled in.
Answer
Identify problem/issue |
Establish Goals(With timeframes) |
Take Action |
Evaluate Outcomes(Has it worked) |
Reflect on process |
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1. Impaired physical mobility related to chronic pain and evidenced by:
2. Exertional discomfort as evidenced by dyspnoea, client complaining of shortness of breath, needing assistance with activities of daily living, need for frequent breaks during activity
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Increased movement within range of motion
Improved respiratory function
|
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Following 1 day of nursing intervention the goals were met as evidenced by Patient being able to move within limited range of motion
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Moving legs and toes assists in walking under nurses’ supervision.
Breathing exercise and use of inhaler process supports in gaining relief from shortness of breath. |
3. Self-care deficits
ADL’s Bathing Grooming Toileting Dressing due to restricted movement |
Foster self-care abilities
Patient can safely wash his face, arms, trunk and perineal area with minimal help |
1. Allow as much time as possible to improve independence within safe limits
2. Support patient in toileting without anyone’s intervention
3. Collaborate by sitting in a tilted back at an angle from 30 to 45 degree while working with the physiotherapist at the time of doing breathe exercise. 4. Involving patient in taking bath and washing face and hands and other hidden body parts whenever required by his own or taking minimal assistance from the nurses. 5. Grooming himself by cutting own nail 6. Dressing up by own or with minimal assistance of nurses. 7. Walking without anyone else’s intervention within a small range of area eg. from cabin to washroom. |
Nigel showered himself with minimal help. Walked to and from bathroom on his own, although quite nervous and worried that he might fall over. |
Doing necessary things by own helps to gain confidence and assists in the self-care progress of patients which leads to fast recovery. |
4.Pain (Right hip)Progression of joint deterioration causing chronic pain to his Right hip
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Identify current level of pain intensity, and determine comfort. & function. Improvement of pain and increase in daily activities
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1. Complete a pain assessment.
2. Barriers to client willingness to report pain and use analgesics or alternative therapies. Fears about side effects and risk of addiction
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New medication improving pain level. Must maintain low level dose twice per day to keep on top of the pain. Nigel needs some encouragement to take it. |
Proper assessment of pain and providing appropriate medicine regarding that is helpful. |
5.Fluid & Nutritional Deficits
Nigel reports of inability to have a bowel movement and associated discomfort |
Client will maintain passage of soft, formed stool every 1-3 days without straining |
1. Avoid eating food that creates digestion problem. Drinking sufficient amount of water regularly before and after meal.
2. Promote measures such as
3. Narcotic pain medicines can create constipation issue. Review of medication process must be done by expert.
|
Unable to have a bowel movement today
Managing additional water today, but still struggling to drink more than 1 l
Medications reviewed and client on several that can cause constipation |
Monitoring the fluid as well as reviewing the medication process helped to get the pt to her normal body weight. |
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6. Impaired skin integrity
Ulcer on sacrum
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Progressive healing of tissues and no new injuries
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1. Reduce irritating moisture
Monitor client’s continence status
2. Improve tissue perfusion
Avoid pressure/massage on reddened areas
Reduce head of bed <30? to diminish pressure on his bottom. Use pressure relieving devices such as air/water/foam mattress Reduce friction & shear Do not position the client on site of skin impairment. Lift and do not drag patient Ensure no wrinkles on bed sheets 3. Improve nutritional status by encouraging Nigel to eat a well-balanced meal, high in protein, Vitamin C etc. Weigh twice weekly
4. Promote wound healing:
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Pressure injury reducing in size. Now size of 20c piece, edges granulating and only a small amount of serous exudates. |
In the morning time, the changing as well as repositioning of dressing is very much effective to prevent further pressure ulcers and at the same time it also assists to prevent infection on the wounds. |
7. Risk for fallsImpaired balance as evidenced by client walking unsteadily, asking for assistance, need to urinate urgently and frequently, uses cane at home to ambulate |
Client will not experience any falls during stay |
1. Orient client to environment. Assess ability to use call bell, use of bed rails, monkey bar, & bed controls
2. Identify factors that may cause or contribute to injury from a fall. Complete FRAT tool and eliminate any risks identified, such as
assist the client in toileting with their schedule Keep the path to the bathroom clear, leave door open. 3. Toilet prior to bedtime, awakening, 2/24 while awake
Lower bed height
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No falls since admission. Hazards in room removed. Bathroom door open at all times, buzzer within reach |
Assessment of hazards in the wards, helped to prevent the risk associated with falls. |
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