...Implement and monitor nursing care for clients with acute health problems. Contribute to complex nursing care of clients. Administer and monitor medications. Administer and monitor IV meds. Assessment 2 Post-op Case Study Assessment 2 Question 1. Identify a minimum of 5 nursing actions, in order of priority you would perform related to above information. Mrs Abu has had a considerable change in her vital signs (blood pressure lowered, her pulse is rapid, her respirations increased and temperature has dropped) form the baseline taken before surgery. These findings alone would be reported to the Registered Nurse and monitored. But because of the changes in vital sings, coupled with Mrs Abu reporting light-headedness and nausea, plus her significant blood loss form the surgical wound, you would be assessing for hypovolemic shock which can be life threatening. As the nurse you would be seeking assistance immediately, assessing her airway, breathing and circulation. Applying oxygen, applying pressure at the surgical site and continuing to monitor (airway, breathing, circulation) and vital signs until help arrives. Mrs Abu should be given nil by mouth as she may return to surgery (Gulanick, Myers, Klopp, Galanes, Gandishar & Puzas 2003, p.329). Question 2. Complete the interventions and rationale in Mrs Abu's care plan related to the following diagnosis |Nursing Diagnosis |Interventions |Rationale ...
Words: 2084 - Pages: 9
...Heritage Assessments Guide Care Plans Heritage Assessments Guide Care Plans As we examine a person’s health status; it is important to note how one has formed beliefs of wellness and health promotion. In a populated, culturally diverse country; it is vital to comprehend and respect the traditions of these beliefs as we teach health promotion, set goals for health restoration, and evaluate health maintenance. Just as recording the vital signs of a patient becomes the blueprint in determining their base line for optimal health; a heritage assessment tool becomes the compass in providing direction toward creating a successful care plan. Evaluation of Heritage Assessments Health assessment tools are useful in evaluating the current philosophy of a patient’s health and wellness. Culture has a multi-faceted effect on a person. It can affect food choices, activity levels, determine when to seek health care, influence lifestyle behaviors, and how health care regimens will be followed. As an individual philosophy is revealed, it can assist in determining which lifestyle behaviors is contributing to the overall health or illness of the patient. The capability of teaching strategies can be rated in an effort to respectfully teach lifestyle modification behaviors. Trends and traditions can be determined with goals adapted to correlate with these cultural attributes (Spector, 2004). Heritage assessments tools also assist in comparing our own belief systems with that of others which...
Words: 1532 - Pages: 7
...Heritage Assessments Guide Care Plans Heritage Assessments Guide Care Plans As we examine a person’s health status; it is important to note how one has formed beliefs of wellness and health promotion. In a populated, culturally diverse country; it is vital to comprehend and respect the traditions of these beliefs as we teach health promotion, set goals for health restoration, and evaluate health maintenance. Just as recording the vital signs of a patient becomes the blueprint in determining their base line for optimal health; a heritage assessment tool becomes the compass in providing direction toward creating a successful care plan. Evaluation of Heritage Assessments Health assessment tools are useful in evaluating the current philosophy of a patient’s health and wellness. Culture has a multi-faceted effect on a person. It can affect food choices, activity levels, determine when to seek health care, influence lifestyle behaviors, and how health care regimens will be followed. As an individual philosophy is revealed, it can assist in determining which lifestyle behaviors is contributing to the overall health or illness of the patient. The capability of teaching strategies can be rated in an effort to respectfully teach lifestyle modification behaviors. Trends and traditions can be determined with goals adapted to correlate with these cultural attributes (Spector, 2004). Heritage assessments tools also assist in comparing our own belief systems with that of others which...
Words: 1532 - Pages: 7
...Assessment tools are useful for nursing care as they can act as a guideline while trying to assess patients. Finding the right assessment tool to match the nursing care going to be given is important. All assessment tools may not match the type of care going to be given. It is important to evaluate the assessment tool not only to match the care, but also to make sure the tool is thorough and useful. The three assessment tools discussed in this essay are an admission assessment by Pamela Craig, a nursing needs assessment tool by the Department of Health Social Services and Public Safety, and a physical assessment tool by F.A. Davis. The admission assessment by Pamela Craig was designed through evaluation of the previous admission assessment tool in which Pamela Craig redesigned it to fix the flaws of the old one. The tool begins with baseline vitals upon admission, with the inclusion of how the patient was brought to the facility and from where. The tool includes allergies, with a section specific to latex allergies. It includes who the information is obtained from, in case the information is not able to be obtained from the patient. There is a place for family history information, as well as history of past diagnoses for the patient. There is a section for nutrition that includes questions about weight loss, nausea and vomiting, enteral feeding, and changes in appetite. The physical assessment part of the assessment tool covers each system. There are boxes to check within each...
Words: 1117 - Pages: 5
...Heritage Assessment Paul Bockoven Grand Canyon University NRS429-V October 14, 2012 Heritage Assessment Cultural assessments can be useful tools for a registered nurse to develop adequate plans of care, especially when it comes to education. They have limits however, as not every individual within a certain cultural ‘category’ can be expected to conform the way their heritage may dictate. Assigning a score to any person to predict how they may act, or learn, is contrary to the direction nursing care plans in general have taken. With that in mind, there is some value to using tools like the heritage assessment as a baseline, or starting point. The problem arises because of this particular tool being used to generalize instead of individualize. Developing a sense of a person’s cultural heritage and assigning an ambiguous score has no real meaning when the focus of a care plan is not supposed to take into account anything that is not directly related to the individual for whom it is being tailored. Standards clearly state that the assessment, planning and delivery of a person's care must be centered on the individual, and developed with them or their significant others (Rollin, 2011, p. 541). A person filling out the heritage assessment may, in fact, not adhere to or agree with it’s findings, may not understand it’s significance and as such, this tool could actually lead a caregiver in the wrong direction. The idea that any person who, according to this tool, identifies...
Words: 1484 - Pages: 6
...The core of assisted living care is individual support. Facilities use an Individual Service Plan (also called a care plan) approach based on the person's daily care requirements. Before move-in, a resident and their family meet with the selected assisted living facility staff to develop a comprehensive, customized care program based on the individual's interests, needs and desires - many times referred to as an assessment. The Individual Service Plan helps define the services provided, in addition to the costs associated with such services. Understanding the specific services offered and the costs associated with each service will help you make a more informed decision when selecting a facility. What is a Care Plan Assessment? Care assessment A care plan evaluation is key to quality care and the strategy for how the staff helps the individual. It lays out what type of care and the time increments administered by each staff member, in addition to additional costs associated with the services. An assessment regularly reviews the resident's care and revised as needs change. It gathers information about how well the resident is able to care for oneself. It measures the person's functional abilities: how well a person walks, talks, eats, dresses, bathes, sees, hears, communicates, comprehends, and recalls. The assessment also defines a person's habits, activities and relationships so that the staff can better assist the resident in living comfortably and feel at home...
Words: 451 - Pages: 2
...INTRODUCTION This essay is all about discharge care planning and will be discussed in two parts, the first part will highlight patient profile, assessment and discharge care planning with evidence based rationale using a framework based on Roper- Logan-Tierney (2000) model of nursing which involve giving nursing care holistically by using 12 activities of living (AL) and also incorporate nursing process to carry out care plan in this essay, which are maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, walking and playing, mobilising, sleeping expressing sexuality and dying. Also with the above mentioned framework, factors influencing the activities of living which include biological, psychological, socio-cultural, environmental and political economic will be considered. Also demonstration of how discharges are planned and problems identified will be discussed, which will involve members of the multidisciplinary team (MDT) and their roles in the patients care, education and support for family/carers. The second part will explore how recent health service legislation has influenced this care plan and its impact on caring of older people with long term condition. In this essay, issues on professional values according to Nursing and Midwifery Council (NMC) Code of Professional Conduct (2008), which include consent, confidentiality, respect and dignity will be undertaking. For the...
Words: 2935 - Pages: 12
...minimise abuse within the health and social care contexts. The caring professions provide some examples of what people thought may have been a good practice of care then but actually is poor or even abusive practice. The main reason why this happens is due to the changes that occurs within working policies. Within my workplace we have different policies that safeguard vulnerable adults, here are some of working practices that I believe help safeguard: • Complaints Policy Effective communication • Record-keeping Policy Risks Assessments • Confidentiality Policy Recruitment procedures • Data Protection Policy Induction • Protection of Vulnerable Adults Policy Training • Whistleblowing Policy Codes of conduct • Care plans – Person Centred Care Reflective practice • Anti – discriminatory / Anti – oppressive practice • Organisations safeguarding policy & procedures Each resident is assessed before arriving at the home, once assessed our nurse manager produces a careplan for that resident. The resident and their family have the right to be involved in developing a meaningful and effective care plan. The nursing home must work with the resident to develop an individualized, written care plan and must update it at least quarterly and any time your condition changes. Each resident important right is to receive good care. To give good care, the nursing home staff must plan to support the needs, abilities, interests...
Words: 2799 - Pages: 12
...Assessment Assessment is the most important part of care planning and delivery. It includes areas such as health and health needs, daily living skills, activity programmes, mobility, mental health, risks to the client, finance, respite, social events/outings, support requirements, spiritual needs and, possibly, accommodation issues (Department of Health, 2000b;Sox, 2004a). As a start, a background check is needed to be able to assess the situation of the patient. Our patient is conscious but was not able to respond properly because of her condition. So we need someone close to the patient or a relative to answer questions needed for the care plan. Data such as previous hospitalization, medication taken and others related to the patient condition is important. Diagnosis The patient was brought in the hospital because of diarrhoea and vomiting. The initial diagnosis is that the patient is dehydrated base on the physical appearance of the patient. Diarrhoea usually gets better on their own, often without treatment. If the diarrhoea continue within several days it is best to check patient’s medical history and physical exam. Planning In planning, the nurse plays an important role in the recovery and stay of the patient in the hospital. The patient upon admission was given attention on the main complain which is diarrhoea and vomiting. However further diagnosis and assessment of the medical team discovered that the patient is suffering from malnutrition. Our plan focuses on...
Words: 600 - Pages: 3
...ROPER-LOGAN-TIERNEY TUESDAY, JUNE 26, 2012 THEORY GROUP A PRESENTS One draw of the field of nursing is the ability for nurses to individualize their care plans for their patients. In order to ensure that unique patients are able to get healthy, they need nursing care plans as unique as they are. This means assessment and evaluation of each patient before and during care. Nancy Roper's desire to become a nurse started in childhood, and as a result of her experiences and education, she, along with two of her colleagues, developed the Roper-Logan-Tierney Model of Nursing to assess patients' level of independence and provide the best individualized care for them. COMPONENTS/CONCEPTS OF THE MODEL Living is a complex process which we undertake using a number of activities that ensure our survival. The current model seeks to define 'what living means, and categorizes these discoveries into Activities of Daily Living (ADL). According to Roper, in a given circumstance, people are able to perform daily activities of living independently but when disease or hindrances occur, the nurse can use these activities of living to be able to assess the patient and identify interventions that can support independence in areas that may prove difficult or impossible for the individual on their own. The model assesses the individual's relative independence and potential for independence in ADLs,(considering their lifespan, development, and the five key factors on a continuum ranging from...
Words: 4036 - Pages: 17
...Systematic Approach to Care through Effective Person-Centred Care Planning. The NHS places a strong emphasis on delivering person-centred care to patients. Patient-centred planning was adopted as national government policy in 2001 via the “Valuing People” paper and more recently as part of the “Valuing People Now” document (DOH,2009). Person-centred planning is now promoted as a key method in delivering the personalisation objectives of the Governments “Putting People First” programme for social care (DOH, 2007). The Coalition continues this commitment towards personalisation of care with its “Capable Communities and Active Citizens” document (DOH, 2010). One key area to ensure that care is delivered in a systematic person-centred way is through effective care planning that involves the patient in the process as a key stake holder. Several systematic models to nursing care are available that will facilitate practitioners in ensuring that all needs of the individual are identified and met. This essay will define what is meant by the term “person centred care”, will explore the systematic nursing models of care delivery and will highlight good practice in constructing person-centred care plans. This will be done using examples of an original care plan (constructed by the author for a real patient whose name has been changed) - and will draw upon information and evidence from a range of contemporary sources. It is appropriate in the context of this essay to firstly define...
Words: 1679 - Pages: 7
...1.1 – Person-centred care is a way of thinking and doing things. It means putting the individual and their families at the centre of decisions and seeing them as experts, working alongside professionals to get the best outcome. Person-centred practise is all about having a focus upon individual’s needs. Every individual has different needs, wishes, choices, likes and dislikes. We must treat everyone fairly and respect their dignity and privacy at all times. We cannot stereo-type or tarnish everyone with the same brush even if they have the same religion, disability or alike in any other way. Despite what they may have in common, every single person is an individual and should be treated like one. 1.2 – All approaches to person-centred practice work well and personally I don’t think there is a particular ‘best approach’. When used correctly, every approach will have the same benefits and outcomes. Also different approaches would work better in some work placements than others the same as work better with some individual’s than others. Below I have compared just a few different types of approaches: Essential Lifestyle Planning. (ELP). This plan looks at: - what people like and admire about the individual - what is most important to the individual - the communication - how to provide the support - identification of successful methods - how to solve problems and/or overcome any barriers ELP is a good for a day to day basis. It’s a good way to start to get...
Words: 3581 - Pages: 15
...Frameworks: A care plan for Mrs Ashton. The following essay will outline and describe the assessment, care plans and evaluation for an adult patient using Orem’s model of nursing. The patient’s name has been changed in order to protect her right to confidentiality which is a requirement of the NMC code of conduct (NMC 2008). Mrs Ashton is 71 years old and she was admitted to hospital following an episode of severe shortness of breath. She suffers from Asthma and has a history of recurrent chest infections and bouts of bronchitis, which she takes antibiotics for in the winter. She takes Salbutamol 100mgs three times a day. However, over the last week she has been feeling very tired and reports an inability to sleep because of the tightness in her chest, coughing up sputum and wheezing. She has lost her appetite and is unable to carry out her usual activities because she experiences difficulty breathing. Mrs Ashton lives alone in a first floor flat. Her husband died five years ago, her only son lives a few miles away and he visits once a week with his children. Mrs Ashton’s difficulty breathing was noticeable during the initial assessment as she had to take long pauses while communicating, her respiration rate was rapid and wheezing was audible. The care plan for Mrs Ashton will be informed by Orem’s Self Care Model. This model takes an individual and holistic approach to health care; it is underpinned by three inter connected concepts namely: the theory of self care, self...
Words: 2444 - Pages: 10
...This essay will examine the challenges of managing Mr. W. Fountain nursing problem on his immobility condition. Developing a care plan for Mr. W. Fountain to aid his recovery due to stroke; resulting to mobility problem. Although, mobility as a result of stroke will be the main focus of this essay but I will also briefly explain the process of developing an effective care plan. I will be relating it to my anatomy and physiology knowledge and show why dealing with my father’s stroke condition some twenty seven years ago make Mr. W. Fountain condition more personal to me. At this stage, I will like to highlight that the nursing management for Mr. W. Fountain will be based on the use of Roper Logan Tierney model in practice. (2003). I will be applying the nursing process that includes delving into the phases and cycle of nursing assessment, planning, implementing and evaluating (APIE). At the implementation stage, a care plan with appropriate objectives, implementation steps and evaluation strategies will be drawn in ensuring that his care is more focused on his needs. I will also be using a range of assessment tools: such as waterloo score and strip, trips and fall. Dignity and respect of Mr. Fountain will be maintained all through in this essay. In conclusion a copy of care, feedback from the Lecturer and reflective summary will be attached. According to Glasper and Mcewing (2010) Stroke occurs if there is an interruption of blood flow to part of the brain. Without blood...
Words: 2921 - Pages: 12
...their spouses (McClive-Reed 2010). Due to the fear that surrounds dementia in older patients, a prognosis could lead to a diminished sense of self and reduction in the quality of life, not just for said patient but also for the families or caregivers. In order to better understand dementia and those who suffer from it, let’s look at potential strategies and challenges to engage dementia clients, how to conduct a biopsychosocial assessment of dementia clients, and take ethical consideration into account in respect to a single client that I have chosen, EP. EP is a sixty-nine year old African American female who was previously diagnosed with dementia as well as depression. I met EP after she was admitted to the short-term involuntary psych unit at the hospital to which I am employed as a mental health associate, making me one of her immediate caregivers. She was admitted after proving to be a danger to herself during screening, where it became known that the patient stopped taking appropriate dosages of her medication and became unable to appropriately care for herself as a result. When EP is doing well with her medications, she is able to live a very independent and healthy lifestyle, but this lasts only temporarily as this is not the first time that she has been admitted here. Her independence is very important to her. EP was born and raised in lower- middle class New Jersey, used to be a nurse, was previously married only once, has two kids and several grandkids. It seems that...
Words: 2450 - Pages: 10
