This assignment will use a case study approach to discuss the plan of care that was observed for a 66 year old lady whilst in clinical placement on the Trauma and Orthopaedic ward. It will do this by highlighting the importance of using four stage nursing process framework to plan care effectively and discuss how the patients care needs were assessed, a plan of care developed and implemented, and finally how the plan of care was evaluated. To comply with the Nursing and Midwifery Council (NMC), (2008) code of conduct that states a person’s right to confidentially must be respected all locations and names have been changed. In addition to this consent was obtained from the patient to use her care plan for this assignment.
Mrs Jane Smith was a 66 year-old lady who lived with her husband. She had no previous medical history, no known allergies and fully independent. She was admitted to the Accident and Emergency department (A&E) complaining of pain, swelling and redness to her left hand, fingers and elbow following a cat bite on her left wrist one week ago whilst on holiday in France.
In A&E, the orthopaedic consultant carried out an examination which resulted in Jane been admitted to the Trauma and Orthopaedic ward due to a suspected diagnosis of osteomyelitis and/or bacterial infection. Osteomyelitis is an infection of the bone that can cause pain, loss of movement and show signs of an infection such as erythema, tenderness and fever. A blood test including a full blood count (FBC) of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and white blood cell (WBC) may be useful in determining an infection (Scholnick, 2012). Her care needs arising from the assessment were identified as treat and maintain the infection, th...
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...he setting of goals and interventions.
Finally the evaluation involved reviewing the care plan by checking if the patient’s condition has improved, goals achieved and interventions applied successfully (Alfaro-LeFevre, 2010). The issues highlighted in the previous stages made it difficult to assess the effectiveness of Jane’s nursing interventions and the achievement of goals as the criteria was unclear. Despite this, all three care needs had either shown signs of improvement and/or not deteriorated further. The patient also expressed that the care plan had working effectively for her because she felt involved in the process as the orthopaedic consultant and nurses talked to her on a daily basis and that it was addressing her needs. To support this Kitwood, (2007) states that it is ultimately the patient who will say if the care plan has met their needs effectively
The NMBA sets out Statements of Principles which provide guidance to nurses regarding processes that will help to ensure that ‘safety is not compromised’ regarding decision making about nursing practice. According to the NMBA, the fundamental motivation for any decision about a care activity is to meet clients’ health needs or to enhance health outcomes. Decisions regarding activities are made in a planned and careful manner and: ‘only where there is a justifiable, evidence-based reason to perform the activity’ (NMBA: 2012, p.6). Furthermore, the NMBA points out that nursing practice decisions are more effective in a collaborative context of planning, risk management, and evaluation. Thus, organisational employers/managers, other health workers and nurses’ work together in sharing a combined responsibility to design and maintain: environments (including resources, education, policy, evaluation and competence assessment) that support safe decisions and competent, evidence-based practice to the full extent of the scope of nursing practice.
On admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings. J.P. was positive for dyspnea and a productive cough. She also was positive for dysuria and hematuria, but negative for flank pain. After close examination of her integumentary and musculoskeletal system, the examiner discovered a shiny firm shin on the right lower extremity with +2 edema complemented by severe pain. A set of baseline vitals were also performed revealing a blood pressure of 124/80, pulse of 87 beats per minute, oxygen saturation of 99%, temperature of 97.3 degrees Fahrenheit, and respiration of 12 breaths per minute. The blood and metabolic panel exposed several abnormal labs. A red blood cell count of 3.99, white blood cell count of 22.5, hemoglobin of 10.9, hematocrit of 33.7%, sodium level of 13, potassium level of 3.1, carbon dioxide level of 10, creatinine level of 3.24, glucose level of 200, and a BUN level of 33 were the abnormal labs.
At the multidisciplinary meeting, the nurse will collect and assess the information provided by the other disciplines and family members stating that the patient is not at her prior level of functioning and then analyze the information to develop a diagnosis of deconditioning. Next, the nurse identifies outcomes for the patient to get stronger, achieve prior level of function, have activities of daily living (ADL’s) met in a safe environment by planning for home health, equipment, and 24/7 supervision through family or placement in a facility. This will be implemented by coordinating delivery of a walker and a 3 in 1 chair prior to discharge to daughter’s home with the home health agency nurse, physical therapist, and aide scheduled to start that day. In a week, the nurse evaluates that outcomes are being met by following up with patient, daughter, and home health agency evaluating that the patient is getting stronger, ADL’s are being met, and will soon be able to return to living independently. To achieve these standards of practice, every nurse should be aware of her own nurse practice act to ensure to be functioning with in the laws of the nurse’s state and to ensure the best outcomes and safety of the patients. In closing, it is every nurses duty to be the best nurse they are capable of being by looking at the scope of nursing practice which gives us the framework to achieve
Facts of the victim’s case are laid out one by one, as if clues to a whodunit game where the culprit is ubiquitous MRSA. Descriptions are lengthy and vivid, describing everything from the patient’s painful symptoms to gruesome surgical procedures that will upset even the toughest of stomachs. This is definitely not the book to read before a large meal. The book reads like an episode of Frontline, keeping the reader on the edge of their seat until the end.
Patients often have complex care needs, and often present with multiple co-morbidities or problems. The process of conducting a comprehensive nursing assessment, and the coordination of care based on these findings is central to the role of the Registered Nurse (NMBA 2006). Evidence-based interventions must then be planned and implemented in a patient-centred approach in order to achieve agreed treatment goals and optimise health (Brown & Edwards 2012).
This essay will critically analyse Care Programme Approach (CPA) assessment and care plan in an OSCE I undertook. By utilising the CPA and sources of current literature, I hope to demonstrate my knowledge and understanding in relation to this skill as well as identifying areas with scope for learning.
...r investigation and then devise a plan for best possible action recognizing the rights of the patient and its benefits followed by the application of the chosen intervention with positive outcome in mind (Wells, 2007). Delivery of excellent and quality of care at constant level (NMC, 2008) must be marked in any responsibilities and duties of the care provider to promote exceptional nursing practice
Dougherty, L. & Lister, s. (2006) ‘The Royal Marsden Hospital manual of Clinical Nursing Procedures: Communication 6th Edition Oxford: Blackwell Publishing Ltd
Case management has become the standard method of managing health care delivery systems today. In recent decades, case management has become widespread throughout healthcare areas, professionals, and models in the United States; and it has been extended to a wide range of clients (Park & Huber, 2009). The primary goal of case management is to deliver quality care to patients in the most cost effective approach by managing human and material resources. The focus of this paper is on the concept of case management and how it developed historically, the definition of case management, the components of case management, and how it relates to other nursing care delivery models.
The purpose of the paper is to discuss the activities involved during the evaluation of a patient. Evaluation of a patient can be seen as the process of examining a patient critically. It comprises of gathering and analyzing data about a patient and the illness (Allan, 2012). The core reason is to make judgment about the disease one is suffering from. Such judgment will guarantee proper treatment and diagnosis. Typically, gathering of information from the patient is the role of nurses while making judgment and prescription is the doctor’s role (Jacques, 1988). In any case all practitioners are required to know how to evaluate a patient.
Mrs S. is an 88 years old female patient who lives on her own, and was admitted into a rehabilitation ward following a hip operation due to a fall at home. She has a past medical history of Congestive Cardiac Failure (CCF), diverticulitis, and asthma. Also, Mrs S presented with rapid weight loss, palpitation, feeling tired, peripheral oedema, fatigue, difficulty breathing when lying flat in the bed, waking up at night with shortness of breath and anxiety. In addition to all that she had a pressure sore in her bottom that was not broken. In order to have good holistic care of Mrs S, the nursing process was used as identified by Sibson. Sibson (2010) identifies four key steps to the nursing process, which are assessment, planning, implementation and evaluation; which are important for ensuring a quality standard of nursing care.
Brunner, L.S. & Suddarth, D. S Textbook of Medical- Surgical Nursing, 1988 6th ed. J. B. Lippincott Company, Philadelphia
The nursing process is one of the most fundamental yet crucial aspects of the nursing profession. It guides patient care in a manner that creates an effective, safe, and health promoting process. The purpose and focus of this assessment paper is to detail the core aspects of the nursing process and creating nursing diagnoses for patients in a formal paper. The nursing process allows nurses to identify a patient’s health status, their current health problems, and also identify any potential health risks the patient may have. The nursing process is a broad assessment tool that can be applied to every patient but results in an individualized care plan tailored to the most important needs of the patient. The nurse can then implement this outcome oriented care plan and then evaluate and modify it to fit the patient’s progress (Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P., 2011). The nursing process prioritizes care, creates safety checks so that essential assessments are not missing, and creates an organized routine, allowing nurses to be both efficient and responsible.
Complex care of patients provides the nurse with a myriad of decisions to be made-however, it must be remembered that although the
While with my patient on the first visit we had set some goals. The goals were for her to walk more with the aid of her walker and for her to recall past events. From the first visit these I identified these issues as problems for the patient. I gave the patient the following nursing diagnoses. Impaired walking R/...