...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...
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...more on the problem of dysphagia and the patient’s needs related to this particular problem. Dysphagia is a condition in which the action of swallowing is either difficult or where the swallowed material seems to be held in its passage (McFerren 2008). The assessment, planning, implementation and evaluation (A.P.I.E) of the patient on admission and discharge will be discussed in further and more precise detail throughout the essay while maintaining the dignity and respect of Mr. Smith. This health problem was chosen due to personal experience with family members who have suffered stroke as well as working with patients on practice placement, and seeing how important it is to respect the person as an individual and to give them the holistic care they deserve and allowing them what independence they have left. Finally the essay...
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...upper arms. P.R. is able to move his shoulders to slightly lift his arms, but has no movements in his legs or the trunk. P.R. requires total assistance for all activities of daily living, and is incontinent of both bowel and bladder function. He speaks primarily Spanish and cannot communicate in English. He is verbally abusive and becomes combative with care givers. He does not have family support in America and is having difficulty adapting to American foods. P.R. has stage III ulcers on each of his buttocks, with various bruises on his lower forearms from trying to attack the faculty personnel. Both feet are starting to turn downward, indicating plantar flexion contractures. The purpose of this paper is to demonstrate the issues that are involved in nursing care, based on Maslow’s hierarchy of needs. This includes physiological, psychological, safety, and social concerns. An example of a complete nursing care plan will be provided for each category of needs identified in P.R’s case study. Patient Care Issues General Spinal cord injuries to an individual present with multiple areas of concerns to nursing care providers. Physiological issues are first addressed when the patient arrives in the emergency room to stabilize the patient according to the airway, breathing, and circulation. Then, spinal cord injury will lead to loss of motor function, urinary/bowel incontinence, sexual dysfunction, trouble breathing, and difficulty sitting upright (O’Sullivan and Schmitz...
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...Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease (COPD) is an irreversible debilitating disease of the airway that is currently the fourth leading cause of death in the United States and is rising. Chronic obstructive pulmonary disease is treatable but currently there is no known cure and it is a major cause of morbidity and mortality. COPD causes reduction in airflow during the ventilation cycle due to the loss of air way elasticity, narrowing of the airways, chronic airways inflammation and over active mucous production (Frace, 2008). Known risk factors for development of COPD include tobacco use (including second hand smoke), air pollution, dust and exposure to chemicals used in the production of coal, cotton and grain. There are many complications of COPD, the most common are pneumonia, pneumothorax, cor pulmonale, atelectasis, and in severe cases there maybe respiratory insufficiency and failure (Bare, Cheever, Hinkle, & Smeltzer, 2010). Nursing management for a patient with chronic obstructive pulmonary disease begins with assessment; gathering information from the patient including detailed medical history, present symptoms and evaluate findings of diagnostic tests. Symptoms vary with each patient, but may include chronic cough, clubbing of the fingers, chest tightness, weight loss, cyanosis, difficulty breathing with a higher rate of respirations and difficulty sleeping (Weber...
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...will be focus on the aspects of communication while the second part will be concentrate on the nursing care. In both parts of this essay the focus will be on the same patient Mrs D Campbell which is not her real name. This is to make sure that the patient privacy and confidentiality will be maintain at all times. According with NHS England, confidentiality Policy, (2014) all members of the staff need to understand the safeguarding of patients confidentiality and respect their privacy concerning information. All information that recognise a patient identity must be avoid unless absolute necessary. The name of the ward in which this patient was admitted also will be change to “silver unit” which is a stroke and rehabilitation ward. In this place the staff is specialised in looking after individuals suffering from acute and chronic problems (strokes) as well as help them with their rehabilitation and social needs. Mrs D Campbell is an 82 years old widow from Jamaica, who lived in London for several years with his daughter and son in law, she was a very healthy independent person that was capable of doing everything by herself and also exercise very often. Mrs Campbell was admitted to silver ward with Left Middle Cerebral Artery Stroke (L MCA). In health settings such as hospitals it is indispensable that the health professionals like nurses, doctors, physiotherapies, health care assistants amount others understand the importance of communication, to make sure that the patients...
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...Content Frame Skip Breadcrumb Navigation Home arrow Chapter 2 arrow Nursing Care Plan Nursing Care Plan Nursing Diagnosis Impaired Verbal Communication r/t sedation, presence of artificial airway, or decreased level of consciousness Long Term Goal: Patient is able to use a form of communication to get needs met and relate to his environment Short Term Goals / Outcomes: Patient and nurse will establish a means of communication Patient will be able to effectively communicate and needs Intervention Rationale Evaluation Assess the patient’s primary and preferred means of communication (verbal, written, gestures) Communication can be frustrating for both the nurse and patient. It is critical that the nurse and patient determine the best method for each patient. Patient can write words clearly on paper Assess the patient’s preferred language and ability to understand written words, pictures and gestures The nurse can not assume that the patient is grasping the information that is provided. In recognition of the vast array of cultures and physical challenges that patient’s face, it is the nurse’s responsibility to communicate effectively Patient speaks and reads English. Recognize that the presence of an artificial airway will hinder the patient’s ability to communicate When air does not pass over the vocal cords, sounds are not produced. Other methods of communication will have...
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...delayed due to poor nutrition and inefficient social interaction as evidence by Jake’s limited speech and often refuses to eat lunch. Goal/s: To promote a healthy nutritional intake and increase social interactions to prevent delayed physical and psychological development. INTERVENTION | RATIONALES FOR INTERVENTIONS | 1. Full health assessment. (Crisp & Taylor, 2010). 2. Assess ADL’s. (Holland, Jenkins, Solomon & Whittam, 2009). 3. Assess activity level. (Holland, Jenkins, Solomon & Whittam, 2009). 4. Refer to Occupational Therapist. (Crisp & Taylor, 2010). 5. Refer to dietician. (Crisp & Taylor, 2010) 6. Refer to motherless mother social group located in Blacktown. (Crisp & Taylor, 2010). 7. Provide strategies for Sally to read to Jake. (Crisp & Taylor, 2010). 8. Provide strategies for Sally to assess safety in her own home. (Crisp & Taylor, 2010). 9. Teach Sally the importance of listening attentively. (Holland, Jenkins, Solomon & Whittam, 2009). | 1. A full health assessment is required to assess the degree of malnourishment in Jake and to obtain a full and complete picture of his current health status, based on the height and weight that has been examined. This will aid in developing strategies which will assist Sally in promoting Jakes appropriate nutritional requirements and any additional physical interventions that may be needed. This will be monitored on a weekly basis in order to assess levels of progress or regress...
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...tool in formulating a health care plan for an individual or family. Nurses therefore have an important role in health promotion and by using the principles of Gordon’s functional health pattern it can assist in developing a diagnosis and nursing care plan. The functional health patterns serve as a framework that is adaptable to all models of care that can be used as a tool for nursing diagnosis for individuals or communities. It is based on the assumption that health and wellbeing is the result of harmony between the body and the environment (Crisp & Taylor 2009, p. 257). The eleven functional health patterns, was used by the nursing student as the basis for an interview conducted with Daphne Trigg. The aim was to identify the functional and dysfunctional patterns in her everyday life. Daphne Trigg is a sixty seven year old woman who lives in the northern rural area of Adelaide. Collection of basic information and sequences of behaviour were captured and these patterns are also used by health professionals to form client data bases, structure assessments and make diagnoses (Gordon 1994, p. 69). This essay will incorporate discussion of relevant literature and aims to gather ‘objective’ and ‘subjective’ (Crisp & Taylor 2009, p. 260) data as this provides an informative awareness of the interviewee’s overall health. Topics covered are the eleven functional health patterns. They consist of Health Perception–health management patterns, Nutritional–metabolic pattern, Elimination...
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...health organization where I can apply my best clinical skills. I have experience working in sub-acute and long term units. Demonstrated ability to communicate patient’s needs to the respective team. Eager to work in high-load environment and achieve the highest level of patients’ satisfaction. CORE COMPETENCIES INCLUDE | | | ☑ Compassionate Care | ☑ Feeding | ☑ Grooming | ☑ Bathing/Dressing Help | ☑ Toileting | ☑ Vital Signs | ☑ Hygiene Standards | ☑ Testing Assistance | ☑ Medication Support | SPECIAL KNOWLEDGE | | | ☑ Safety and Monitoring | ☑ HIPAA Regulations | | ☑ Medication Risks | ☑ Healthcare Software | ☑ Medical Terminologies | Personal Summary: Excellent clinical, customer service and communication skills. Ability to quickly learn new concepts and skills. Knowledge of medical terminology and infection control standards. Knowledge of age specific developmental factors specific to adult and geriatric residents. Excellent verbal and writing skills. Certified in CPR Work History:West Caldwell care center165 F airfield ave, west Caldwell NJ.( 9732261100) Certified Nursing Assistant/ restorative Aide (2011- Present) Provided nursing and nursing related services to clients Maintained homelike environment for the clients Protected and promoted client rights and assisted the person to maintain independence. Ensured that each client’s needs...
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...Nursing Theory Plan of Care Fintan O’Connell NUR/513 May 23, 2012 Francine McDonald Care Plan for Ronald Issler |Nursing Process |Data and Relevant Information | |1. Breathe normally |Complains of shortness of breath, oxygen saturation 88% on room air, | | |heart rate 58, chest x-ray with bilateral lower lobe infiltrates, | | |history of DVT. | |2. Eat and drink adequately |Height 6 ft., weight 147 pounds. BMI 19.7 (lower range of normal). | | |History of congestive heart failure, takes diuretic. Hemoglobin and | | |hematocrit levels low (HGB 10.4 gm/dl, HCT 29.6%) | |3. Elimination of body wastes |History of congestive heart failure (as noted above), elevated | | |creatinine level of 2.0 mg/dl | |4. Move and maintain posture |Increasing weakness...
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...Course Project Milestone #2: Nursing Diagnosis and Care Plan Form Your Name: Kayla Bright Date: April 10, 2014 Your Instructor’s Name: Professor Hudson Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 250 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language. Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone2_Form_Smith” When you are finished, submit the form to the Milestone 2 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment. 1: Analyze Assessment Data: Based on the health history information, identify the following: A. Areas for focused assessment (30 points) Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History. From the conversation with JAW on her medical history she is in denial about the occurrences that is happening in her life which is making her non-compliant about taking her medications as prescribed. It appears that taking her medications will make her an unfit mother in the presence of her children according to JAW. Being a hospital corpsman in the Navy she is well aware of the ramifications about taking medications...
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...Running Head: NEWBORN ASSESSMENT AND CARE PLAN Newborn Assessment and Care Plan Newborn Assessment On 1/29/09, at 0610, 39 week gestational age, 7lb 4.6oz, black male was born to 18 year old mother. Infant born via vaginal delivery with assistance of vacuum extraction, nuchal cord x1 noted. Mother received adequate prenatal care beginning at 8weeks. Prenatal medications included Iron supplements and prenatal vitamins. Prenatal complication included pregnancy induced hypertension. Onset of labor 0647, full dilation 1705, and delivery of infant at 1810. Apgar scores 6/8.Weight 3305gms, length 20 inches, head circumference 12 inches, chest circumference 12 ¾ inches, abdominal girth 12 inches. The infant is alert and active. Anterior fontanel is soft and flat. No oral lesions. Head caput/ molding, elongated with edema, abrasion noted from suction. Color is pink and changing all over (African American.) Skin is warm, dry, and well perfused. No rashes, vesicles, or other lesions noted. Birthmark present on forehead approximately 2cm. Bilirubin test ordered. Lanugo present. Hair pattern is scattered evenly all over, fine texture and moderate amount. Eyes symmetrical and in midline. No discharge present from eyes. Eyes move from left to right and sclera is white. Eyebrows are fine and symmetrical. Nose is patent and midline. Ears present symmetrically. Mouth midline. Gums and tongue pink and moist. Cheeks symmetrical with no lesions. Saliva present. Chin well aligned on face...
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...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 ...
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...Nursing Management 1 Running head: OVARIAN CANCER Nursing Management of a Patient with Ovarian Cancer Jane A. Student Pasadena City College Nursing Management 2 Nursing Management of Patient with Ovarian Cancer H.S., a 57 year old female with a medical history of hypertension and chronic kidney disease, was diagnosed with a Stage IIIB clear cell carcinoma of the ovary and had surgery in April of 2007. When the patient began to have physical discomfort, an exploratory lapartomy was performed. A pelvic mass had developed post peritoneal chemotherapy. The patient had surgery to remove the intraperitoneal port, pelvic mass fluid drainage and pelvic biopsy. Often patients with cancer develop cachexia and should be assessed for adequate nutritional intake. Martin (2006) states that one of the greatest challenges for a woman with ovarian cancer is malnutrition: she may have little appetite as a result of treatment of advancing disease, causing her to lose weight. Pathophysiology The symptoms of ovarian cancer are vague and the causes may be related to several factors. As Bohnenkamp (2007) has explained, one or more risk factors may increase the likelihood of developing ovarian cancer, but their presence does not guarantee the cancer will occur. Martin (2006) claimed that the most significant risk is a positive family history of the disease; it is present in about 10% of women with the disease. Although it is not known if H.S. had a history of ovarian cancer in her family, Ignatavicius...
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...NM1704: Applying a model of nursing roper, logan and tierney model This essay explores the preoperative care provided to one patient in a London hospital during one shift. This care was influenced by the holistic perspective to health. Arsing from the Greek for ‘whole’ this acknowledges physiological, psychological and social factors impacting the patient’s condition. (McFerran & Martin, 2008) It seeks to offer treatment inclusive of these factors rather than treating physical symptoms of a diagnosed disease in isolation. This essay will examine this within a Model of Nursing used in my clinical placement area - the Roper, Logan and Tierney model. The identities of both hospital and patient have been altered to maintain confidentiality and comply with the NMC Code of Conduct. (Council, 2008) During my placement I worked on a coronary care unit where I cared for a patient herein called Peter, a 60 year old White British male. Peter was single, lived alone and unemployed. He had a history of low mood and was admitted to a neighbouring hospital suffering symptoms of acute alcohol withdrawal syndrome (acute confusion, delusions and tremors). This arises when an individual reduces or stops alcohol consumption after prolonged periods of excessive alcohol intake. This can lead to tolerance, physical dependence and physical disturbances upon withdrawal due to the central nervous system reacting in a hyper-excitable state. (About.com, 2010) He was transferred to my area...
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