Nursing Assessment and Care Plan Using Orem's Theory - Case Study Example

Nursing Assessment and Care Plan using Orems Theory Introduction Nurses play an important role in the health promotion of an individual due to their direct contact and proximity with the patients. The 3 basic roles of a nurse are that of a practitioner, leader and researcher. As a practitioner, the nurse attends to all the medical needs of the patient and as a leader she takes decisions which relate to, influence and facilitate the actions of others with an aim to achieve a particular goal. As a researcher, the nurse aims to implement studies to determine the actual effects of nursing care and to work towards further improvement in nursing care (Nettina, 2006). The role of nursing is authenticated in helping people move towards independence in all activities of daily living. They take up the role of a family member. In order to deliver appropriate interventions, nurses must perform a holistic assessment of the patient before arriving at the diagnosis and develop a care plan based on the nursing diagnoses and identification of goals. The care plan must be influenced by a suitable nursing theory. In this essay, holistic assessment of a patient with diabetes mellitus and ischemic heart disease, presenting with myocardial infarction will be elaborated and discussed with reference to Orems nursing theory. Holistic assessment of the patient Model of nursing used: Orems Self-care Model The Orems self-care model of Nursing incorporates 3 subtheories: self-care deficit, self-care and nursing systems (Comley, 1994). According to the self-care deficit subtheory, "individuals may experience self-care limitations related to their health state and may benefit from nursing provision of this care or augmentation of their own self-care efforts" (Comley, 1994) The theory considers care of one-self and that of dependents as a type of learned behavior which causes regulation of the structural integrity, development and functioning of the humans. The nursing system ensues at that point of time when the nurse intervenes with the patient either to prescribe medication or to provide care that is intended to take care of self-care deficit and regulate his or her own capabilities of self-care (Orem, 1985; cited in Comley, 1994). Actions intended to meet various self-care requisites are known as "therapeutic self care demands" and when these exceed the basic capacity of an individual, deficits in self-care ensue. It is during such deficits that legitimization of nursing intervention occurs (Orem, 1985, cited in Comley, 1994). Through appropriate nursing care, compensation and support for those self care activities which the client is unable to perform is executed. The compensatory systems can be either complete or partial based on the needs and deficits of the individual (Orem, 1985, cited in Comley, 1994). The theory proposes that nurse must exert care by assisting patients with various self-care practices and to maximize self-care capabilities of the patients. Such a support is critical in situations when the patient is unable to maintain the quality and quantity of self-care that is critical to sustain life and good health, to recover form disease process and injury and to cope with various ill-effects of poor health. Clinical History Name: Mr. X (name changed for confidentiality reasons) Age: 50 years Sex: Male Occupation: Agriculturist Presenting complaints: Sudden onset of chest pain, severe restlessness, nausea and sweating since 30 minutes. History of presenting complaints: The pain is severe and radiating o the left shoulder joint. Patient also complains of severe tiredness and dizziness. There is no history of fever, cough, expectoration or palpitations History of past illness: The patient is a known case of diabetes mellitus and ischemic heart disease since 10 years. s. Personal history: The patient has normal diet and sleep. His bowel and bladder habits are regular. Though an agriculturist, he leads a sedentary life and does not exercise regularly. he is neither a smoker, nor an alcoholic. Family history: There is no family history of diabetes or hypertension or heart disease. Physical examination General examination: The patient is moderately built and nourished. He is conscious, alert and quite. He is afebrile and in pain. He is pale and diaphoretic. There is no icterus, cyanosis, koilonychia, clubbing, edema or lymphadenopathy. Skin and appendages are normal. Perfusion of the skin is decreased. Pulse rate is 120per minute. Blood pressure is 160/110mmHg. Respiratory rate is 40 per minute. Cardiovascular examination: Pulse rate is 120-130 per minute. The rhythm, volume and equality is normal. There is no apex-pulse deficit, radio-femoral delay or carotid bruit. Blood pressure is 160/110 mmHg on both arms in sitting position. There are no dilated veins or any scars seen. There is no left parasternal heave. Apex beat is normal. No thrills or any other pulsations felt. Percussion of the heart area is normal. First and second heart sounds are heard and normal. Third heart sound heard. Diastolic murmur of mitral regurgitation is heard. Other systems examination: Normal Clinical Diagnosis: Myocardial infarction Investigations ECG: ST-segment elevation of more than 1mm in contiguous leads. Spot glucose: 200mg/dl Serum troponin and myoglobin: suggestive of ischemic damage CRP: raised ESR: elevated Complete blood picture: leukocytosis Pulse oximetry: 88 percent in room air. Care Plan Nursing diagnosis-1 Acute pain related to oxygen supply and demand imbalance Goal Reduction of pain Nursing interventions The patient must be positioned in semi-Fowlers position. Oxygen must be administered either through nasal cannula or through mask to maintain saturations above 92 percent. Nitroglycerine and morphine must be administered based on vital signs. Blood pressure must be monitored closely. Heart rate, ECG and rhythm must be monitored continuously. Thrombolytic therapy must be administered and monitored. Signs of bleeding must be observed after initiation of thrombolytic therapy (Nettina, 2006). Rationale Positioning in semi-Fowlers position ensures rest and adequate chest excursion, decreasing cardiac working and at the same time increasing the availability of oxygen. Oxygen therapy decreases pain. Nitroglycerine and morphine decrease pain by decreasing venous return to the heart and by decreasing cardiac work. Since both these medicines decrease blood pressure, monitoring for hypotension is essential. Continuous cardiac monitoring is necessary to ascertain arrhythmia and heart block. Thrombolytic therapy relieves coronary occlusion, but may cause bleeding. Nursing diagnosis-2 Decreased cardiac output related to decrease in cardiac contractility and possible dysarrhythmias Goal Improvement in cardiac output Interventions Intravenous fluids must be administered as ordered. The patient must be closely monitored for signs of left ventricular failure like crackles and S3. urine output must be monitored hourly. mental status and hemodynamic status also must be monitored. Vasopressors may be administered to titrate response to blood pressure (Nettina, 2006). Rationale Nitrates and morphine decrease venous return to the heart and hence intravenous fluids may need to be administered. Decreased myocardial contractility may result in left ventricular failure. Decreased urine output suggests decreased blood flow to kidneys. Change in mental status indicated decreased cardiac output. Nursing diagnosis-3 Increased blood sugar levels due to improper dietary habits and noncompliance with medications Goal To bring blood sugar levels to normal range. The goal should be to achieve glycosylated hemoglobin of Read More