Question :
Introduction:
Nursing Care Plan (NCP) is the organised assessment, nursing diagnosis (identification of patient’s problems), setting the goals, and the establishment of methods and strategies base on evidenced based practice for achieving them. (Uhlrich et al., 2005).
Aim of this assignment:
The aim of this assignment is to assess the student’s understanding on the implementation of nursing process by developing a Nursing Care Plan for patient based on the scenario given.
Structure of the Assignment:
1. Assess and report medical/surgical history of patient based on the case study given.
2. List down the potential nursing diagnosis for the patient.
3. Select the most priority nursing diagnosis to be addressed.
4. Focus your discussion on the selected nursing diagnosis as to why they are important to be addressed and what impact do they have on patients daily functioning or maybe other issues. (E.g. knee pain may impact patient’s movement).
5. Plan your care including the necessary to have referral to other professionals such as physiotherapist or social worker.
6. Write your care plan in the essay format. (refer to sample given) Includes the aim and goals of the NCP, planning and implementation of care, evaluation of the effectiveness of the intervention and rationale using best evidence based reasons for the proposed plan.
Case Scenario
Mrs D, a 45-years old housewife weighing 85kg presented to the outpatient department with complaints of intermittent colicky pain in the right hypochondriac region since 2-weeks. It was associated with frequent anorexia, nausea and vomiting. She also presented with low grade fever since 1-week. She was examined by the surgeon and a couple of investigation were ordered. Based on the findings of the diagnostic tests, she was diagnosed to have cholelithiasis and was admitted to your ward for further management.
Case Scenario
Sample Essay:
Introduction
Nursing process is define by ……….as……….
This essay will discuss on a Nursing Care Plan proposed for the following case study:
Medical history of patient
Mrs. Smith is an 80yrs old lady widower living alone in a bungalow. She was admitted to the ward from A&E. She depends on his son who lives a few miles away and visits him twice weekly. Mrs. Smith was diagnosed of COPD 10 years ago and Ischaemic heart disease 4 years ago. He smokes 40 cigarettes a day. Currently, he is on Salbutamol 200mcg/dose dry powder inhaler 1 puff as required, Spiriva 18mcg inhalation powder capsules once a day, Nicorandil 20mg tablets one twice a day, Simvastatin 40mg tablets once daily and Glyceryl Trinitrate 400mcg/dose pump sublingual spray as required. Over the past few years, he has been admitted to hospital three times owing to exacerbation of COPD and has had a bad chest infection yearly for the past few years.
Mrs. Smith has not been well for two days and has been coughing and wheezing with increased phlegm and a temperature. Mrs Smith lost quite remarkable weight in the past few months because she has not been eating and drinking well. Mrs. Smith could hardly finish a sentence without gasping for breath and appeared anxious when the Physician referred him to hospital.
Nursing Care Process
The nursing care process should be conducted for Mrs Smith as follows;
Assessment
Assessment is the first stage in the nursing process. Kozier, et al (2012) stated that assessment is a systematic collection of data with a view to identifying the patient’s actual and potential health problems. A complete and holistic assessment should take into consideration the individual’s psychological, social, spiritual and cultural needs (Matthews, 2010). Collected data can be subjective or objective (Hoffman, Aitken and Duffield, 2009). Full assessment should be systematic, patient oriented, evidence based and holistic; and nurses should seek informed consent from a patient before initiating assessment, any treatment or care (NMC, 2008). Consent should be sought from Mrs. Smith prior conducting an assessment on her. There are three types of assessments namely; mini, comprehensive and targeted. Targeted assessment (problem oriented) is suitable to be used in assessing Mrs. Smith.
Identify Potential Nursing Diagnosis
The potential nursing diagnosis for Mrs Smith are tabulated on Table 1.0.
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Identified nursing problems
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Descriptions
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The Prioritized Nursing Diagnosis for Mr Smith was identified as;
1. Recurrence of her wheezing attack.
The following factors could be the causative factors for the recurrence;
2. Mrs Smith were not informed about her condition and treatment
Mrs. Smith was not given a verbal informative about the important of taking nebulizer as ordered and the reason for doing this by the nurse. Verbal language is one of the vital ways in which we communicate and is more helpful way in both gathering and updating patients of their disorder (Berry, 2007).
Communication can be verbal and non- verbal. Peate (2005) states that non- verbal communication reinforces a verbally communicated message. Non-judgemental interactions are focused on therapeutic communication, helps settle emotional conflicts and supports heart to heart talks allowing a patient to feel safe and free to share their true feelings, fears, values, hopes and ideas.
3. Mrs Smith were not advised on how to take the nebulizer
Environmental obstructions such as a busy ward or a strained nurse can be the cause for the nurses unable to attend to the patient’s needs, education and suppot (Endacott & Cooper, 2009). On the other hand nurses must remain sympathetic all the times towards their clients regardless of pressure altitudes and amount of work (Von Dietze & Orb, 2000).
