A Plan of Nursing Care - Case Study Example

Implement and evaluate a plan of nursing care HLTEN504C Assessment Event One of Two This Assessment Event contributes to the grading criteria for this unit Instructions for Student To be completed in your own time Read the following ISBAR clinical handover on page nine Complete Part A and Part B: Part A – 1000 words Part B - 1000 words Instructions for Part A and Part B are on page ten Marking criteria for the Assessment Event is on page 11 In bed 1 is Constance Green. She’s a 74 year old lady who presented at 2200 with abdominal pain, vomiting and diarrhoea from a confirmed bowel obstruction. She’s on the emergency theatre list but I haven’t had a chance to do any prep with her other than the admission sheets sorry. We’ve had a lot of difficulty managing her pain and nausea overnight, she’s tachycardic and her BP is in the clinical review section on her SAGO. I’ve contacted the surgeons and they want her in theatre asap. She has peripheral IV fluids, PRN morphine and metoclopramide, no known allergies and no significant comorbidities. She lives in a supported living retirement village where she moved about six months ago after her husband died. In bed 2 is Jacqueline Mast. She is a 61 year old woman who presented via ambulance yesterday at 1400 with infective exacerbation of COPD. She has several trigger factors in her home but usually manages her disease independently. She lives alone but her sister provides additional support as she needs it. She reports that her breathlessness is settling and is tolerating the IV antibiotics without side effects so far. She said she often gets diarrhoea with ampicillin but hasn’t had any yet. She is able to mobilize around the bed, is self-caring with minimal support and is managing her metered dose inhalants (MDI) with minimal prompting. Her vital signs are within normal limits and she’s expecting another 3 days of IV antibiotics before discharge. She’s eating and drinking adequate amounts. In bed 3 is Brian Smith. He’s a 70 year old gentleman with type 2 diabetes who was brought in by ambulance with a right sided occlusive stroke. He has a dense left hemiplegia and requires lifters and assistance with repositioning. He is aphasic and seems fairly distressed by his incontinence. He’s NBM awaiting speech therapy swallow assessment and I’ve put a uridome on him for now to collect a MSU as his urine is a bit smelly and he’s got a low grade temp. His wife June has been staying at his bedside as he seems to be more settled with her presence but I’ve encouraged her to take a break today as she’s looking really tired. I’ve also made a referral to the social worker to see June today. Brian is co-operative with cares. Other than his temp his vital signs are within normal limits. Bed 4 is Sakiya Chu she’s a 4 year old girl who’s been put in the side room here while they’re preparing her an acute bed on the paeds ward. Her mother Ushi is with her but speaks limited English. Sakiya’s preferred name is Kylie and she’s bilingual and really quite bright and fearless for a four year old but she’s working hard. A Careflight transfer has been organised but it’s been delayed and paeds can’t put anyone else in their high acuity bay till they clear some space. There’s no ETA for the bed yet so she may jbe here a while. Kylie has recently been diagnosed with asthma and has an URTI that’s presumably caused this exacerbation and admission. She’s on 2nd hourly salbutamol nebs that she’s tolerating well. She usually uses an MDI at home. I’ve never looked after children before so I’ve printed the NSW Health Children and Infants Acute Management of Asthma policy and left it with her chart. She’s needing a lot of encouragement for oral intake including her medications. She’s looking really tired and her Mum is too. Part A Part A requires you to develop a focused plan of care for one of the clients described (client will be identified by the teacher). This must include identification of two priority patient problems (actual/potential) with SMART1 goals, and at least six nursing interventions (actions) with rationales (justification or reason) and evaluations/outcome measures. An example of a problem is diarrhoea. An intervention may be to collect a stool specimen. A rationale for this action may be to determine cause. The plan of care should be supported by relevant contemporary academic literature. The plan of care may be presented in essay or table format such as the example provided below. The plan of care will focus on the patient in bed 2. A 61-year old female admitted with infective exacerbation of Chronic Pulmonary Disease (COPD). Jacqueline Mast’s COPD is associated with a number of triggers factors in her home, which are not mentioned in the scenario. The identifiable problems in this patient include breathlessness and diarrhoea. Since these two problems are manageable, most of the interventions that will be covered by this paper will be non-pharmacological interventions. Problem 1: Breathlessness SMART Goal: Minimizing the level of breathlessness and providing treatment for underlying conditions that could be intensifying the breathlessness. Intervention Rationale Evaluation/outcome measure 1 Assisting client to assume position of comfort Elevating the head of the bed makes the respiratory function easier as a result of gravity. Supporting legs and arms with pillows, table, and other things assists in reducing muscle fatigue and may aid chest expansion[Gar11]. The client will assume a relaxed position within 5 minutes 2 Encourage pursed-lip or abdominal breathing exercises Provides the client with a way to handle or control breathlessness and minimize air-trapping Reduce breathlessness within 20 minutes 3 Increase fluid intake per day and provide tepid or warm liquids. Intake of fluids between the meals should be recommended rather than during the meals. Hydration assists in reducing the viscosity of secretions, enabling expectoration. The use of warm fluids could reduce bronchospasm[Bar13]. Taking fluids during the meals may increase pressure on the diaphragm and gastric distension. Reduces congestion and hence, reduces breathlessness 4 Maintaining environmental pollution to least possible such as feather pillows, smoke and dust, according to the client condition Helps in reducing allergic respiratory reactions that may exacerbate or trigger attack of acute episode. No more attack episodes in the friendly environment. Since the client is not likely to get an attack in friendly environment, there are few chances of experiencing breathlessness 5 Observing the characteristics of the cough and assisting with actions to enhance success of cough effort. Since the client is elderly, cough may be persistent but ineffective. The position that a cough is most effective is in a head-down or upright position after chest percussion[Ves13]. Effective cough will reduce breathlessness by more than 80% 6 Chest X-ray, pulse oximetry, and monitoring and graphing serial ABGs. Helps in establishing the baseline for monitoring regression or progression of disease process and complications[Eve10]. Exact causes of breathlessness will be established and treated Ampicillin is known to cause some side effects such as rash, nausea and diarrhoea. In this scenario, the client indicates that she often gets diarrhoea with ampicillin but has not had any yet. Therefore, the interventions will focus on preventing diarrhoea. Problem 1: Diarrhoea SMART Goal: Prevent diarrhoea from occurring Intervention Rationale Evaluation/outcome measure 1 Assessing the pattern of defecation or having the patient maintain a diary that includes present bowel regimen, changes in perianal sensations, medications, exercise patterns, history of bowel habits, fluid intake, type and amount of food consumed, consistency and frequency of stool, and time of day defecation takes place. Assessing the defecation pattern assist in guiding the treatment. Correct treatment will be provided to the client 2 Since the diarrhoea is linked to an antibiotic therapy, it is advisable to consult with the primary care provider about the use of probiotics or probiotic dietary supplements. Probiotics have been proven to prevent diarrhoea associated with antibiotics in a number of clients. Antibiotic-related diarrhoea will be fully treated within a day 3 Monitoring the client closely to understand whether the diarrhoea is being caused by impaction. Impaction should be removed as ordered Impactions are very common in elderly and they are likely to cause diarrhoea No diarrhoea associated with impactions as they will removed if established to be the cause of diarrhoea 4 Provide emotional support to the client Elderly may feel a bit embarrassed when they experience unpredictable episodes of diarrhoea. It may also lead to a feeling of powerlessness and social isolation. The client will “feel at home” and she will share all her experiences without feeling ashamed. 5 Weighing the client each day and noting any decreased weight. Taking accurate daily weight is very important because it is a significant indicator of the body fluid balance Right advice on fluid and food intake will be provided after observing the recorded daily weight 6 Evaluate all the medications the client is taking A number of medications may result in diarrhoea, especially in geriatric clients. Some of these medications include antibiotics, oral hypoglycaemia agents, anticholinergic agents, NSAIDS, Hx-receptor antagonists, ACE inhibitors, propranolol, digitalis, and many more[Ves13]. Apart from ampicillin, many drugs may cause diarrhoea in old people. No medications that is causing diarrhoea will be given unless the doctor advices otherwise Part B Part B requires you to present a shift plan, such as the example provided below, to demonstrate implementation of planned care for all clients addressed in the ISBAR handover. The shift plan should consider the care requirements for each individual. Include a reflective discussion of the plan. This reflection includes describing rationales for priority care interventions, time management strategies and reflection on how you have used these strategies previously. TIME Interventions / care requirements Bed 1 Bed 2 Bed 3 Bed 4 1400 1420 2200 Nursing. Constance Green presented with abdominal pain, vomiting and diarrhoea. Case of bowel obstruction confirmed. Put on emergency theatre list. Monitor overnight. Nursing. Jacqueline Mast presented with infective exacerbation. Several trigger factors identified Nursing. IV antibiotics and ampicillin administered. Mast’s breathlessness settling and no side effects reported. Suffers from diarrhoea with ampicillin but has not had any so far. She can move around the bed and is self-caring with little support. Monitor to see whether they will be any episode of diarrhoea. 0800 0830 Nursing. No prep done. Difficulty managing her pain and nausea overnight. Green is tachycardic and her BP is in the clinical review section on her SAGO. Nursing. Contacted surgeons and they ordered the client to the theatre immediately. Green has peripheral IV fluids, PRN morphine and metoclopramide, not prone to hypersensitivity and no significant complications. Proceed with the surgery Nursing. Mast is managing her metered dose inhalants (MDI) with little prompting. Vital signs within normal limit. She is drinking and eating adequate amounts. Recommended to continue with the IV antibiotics for 3 days before been discharged. Monitor her eating and drinking and ensures that she drinks about 3000ml per day. Nursing. Brian Smith presented with a right sided occlusive stroke. He has type 2 diabetes. Smith has left hemiplegia, thus lifters and assistance with repositioning has to be provided. Smith is aphasic and is embarrassed by his incontinence. He is NBM and speech therapy swallow assessment will be conducted. Nursing. Uridome put on him to collect a MSU. Smith has a low grade temperature. His wife June encouraged to take a break. June to see a social worker later. His vital signs are within normal limit except the temperature. Continue monitoring the temperature. 1200 1600 1900 Nursing. Sakiya Chu present with an asthma exacerbation. Recently diagnosed and URTI is thought to cause the current exacerbation. Salbutamol nebs administered. Waiting to be transferred to paeds ward. Sakiya prefer the name Kylie. NSW guidelines for paeds asthma to be used. Continue with salbutamol nebs on hourly basis. Nursing. Kylie still waiting to transferred to paeds ward. She uses an MDI at home. Encourage oral fluids, diet and medications. Make sure she is in comfortable position as she looks very tired. Continue with her medications and monitor vital signs. Nursing. Transferred to the paeds ward. Education given to Mum on giving oral medications. Continue with the medications Reflection Reference List Gar11: , (Garcia-Aymerich, et al., 2011), Bar13: , (Barnes, 2013), Ves13: , (Vestbo, et al., 2013), Eve10: , (Evensen, 2010), Read More