Major goals of nursing embrace identification of clients and their family responses to illness, determination of their level of health, and needs for nursing assistance (Ackley & Ladwig, 2016, p. 2). According to Registered nurse standards for practice (Nursing and Midwifery Board of Australia [NMBA], 2016), the complex nursing care includes provision of emotional and physical care, counselling, advocating, guiding, and teaching through implementation of essential interventions. The nursing process provides an effective framework to deliver individualised care, that based on the holistic assessment of information about the patient. Understanding of patient history, which include values and believes, lifestyle, health issues, and related experiences; is crucial for planning of scheduled actions, as it plays an important role in the clients’ abilities and desires to accomplish their personal goals (Berman, 2016, pp. 184-185). Furthermore, critical thinking, evidence-based guidelines and tools for providing care, accounting on client’s preferences for each individual clinical situation, interprofessional collaboration, safety, and quality improvement are vital characteristics of excellence in providing care, that results in the best possible health outcomes for patients.
A case study concerns Mrs B. She is an 86 years-old female, who lives independently in a community residential village. Mrs B reported, that three months ago she injured her left shoulder in a spa centre. She stated that her arm stuck in a rail, when she was coming out the spa pool. An ice-pack and the supporting arm-sling were supplied by pool stuff. After this event, she attended primary care clinic for checking-up her left shoulder and was diagnosed with partial tendons splitting. Past 6 months Mrs B took pain relief medication and limited her exercising program. She reported, that she could not carry out her daily activities and walk around as the lack of strength in arm deprives her ability to keep a walking frame properly. Moreover, Mrs B complained, that prescribed pain relief treatment is not successful and pain disturbs her significantly during night time.
Past medical history of Mrs B includes osteoporosis, visual impairment, X-ray and blood tests related to the recent diagnose. It includes allergy to penicillin and vitamin D prescription. Social history states that Mrs B lives along for a long time. Despite ambulating with the walking frame, she has never accessed basic home care services. A community nurse visits her once a week, while a neighbour friend visits her occasionally. Mrs B attends leisure centre four time a week, where she participates in exercise program for older adults. Now she is referred in a ward for further admission.
Admission of Mrs B to the ward include room preparation, comprehensive assessment, on-going care plan and discharging (Berman, 2016). Before admitting the patient, a nurse considers measures should be taken to reduce stress and anxiety of Mrs B from hospitalisation. As Mrs B lives independently and provides efficient self-care, the actions must be addressed to maintaining privacy, autonomy and independency of self-care provision (Standards 1, NMBA, 2016). For example, a single room for this patient is preferable in order to secure client privacy and confidentiality, which are highly evaluated by patients (Whitehead & Wheeler, 2008). However, if this is not achievable, she must be admitted in shared room with limited number of female older patients. Such allocation may help create an environment close to her neighbourhood. Comfort in the Mrs B room and encouragement to self-caring can be achieved by placing personal hygiene products, water, and information booklets at a bedside table to the right side close to the bed, as there is a limited manipulating by right proximity. At the same time these measures account prevention of increased falls risks for her age group (Standard 10, (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2012).
Patients suffer from disorientation in unfamiliar environment with unknown hospital personal, as their lifestyle and daily routine are changed during admission (Berman, 2016, p. 299). Printed materials in the room, which include ward facilities locations, meal time, visiting time, risk reduction measures and procedures descriptions, aim to encourage the patient planning her daily routine and support her independency in self-care (Standard 3.7, NMBA, 2016) . Additionally, a walking frame and a wheelchair must be placed in Mrs B room in order to empower the patient with independent walking and visiting bathroom (Standard 2, ACSQHC, 2017). All these measures promote the patient’s health adherence to achieve the best possible outcomes and respect rights to get safe and respectful health care (ACSQHC, 2008).
On admission Mrs B’s past medical, social and family history must be completed with comprehensive physical assessment and general survey (Standard 3, NMBA, 2016). These must be provided in accordance with established care setting’s frameworks and guidelines after informing Mrs B about the purpose and provisional way of the assessment in timely appropriate manner (Standard 2.2, NMBA, 2016). The informed consent from Mrs B involves her in care process (Standards 2,5) , however it supports an establishing of therapeutic relationships between her and the nurse (ACSQHC, 2017). The food requirements are also important information, that must be obtained during general survey. The older patients have special protein requirements, which support their skin integrity and normal metabolism (Capra, 2006). Furthermore, the special food requirement must be completed with efficient vitamin D and calcium intake, as she has osteoporosis.
After obtaining informed consent, the hand hygiene must be performed according to Standard 3 (ACSQHC, 2017). Hand hygiene is an important preventive measure of spreading nosocomial infections, which can affect the health of Mrs B, as she related to geriatric population (Standard 6.1, NMBA, 2016)).
Maintaining of accurate and timely documentation is obligation for registered nurses (Standard 1.6, NMBA, 2016). During admission the hand band with personal information must be compared with her identity. The matching process reinforces avoiding mistakes in her caring and further documentation. (Standard 6, ACSQHC, 2017). Allergic status to penicillin must be visualised by red hand band allowing to avoid detrimental consequences of its administration (Standard 4, ACSQHC, 2017).
The accurate information can be organised according to Gordon’s Functional Health pattern for further analysis (Berman, 2016, p. 195). At the same time the ability of Mrs B. to self – maintaining can be assessed with IADL (Lawton & Brody, 1 October 1969) as she mentioned, that her lifestyle is affected by loss of strength in her left arm. This information is crucial for long-term care, which is organised on discharge. Likewise, the pain in shoulder, as the main complication from the client, can be assessed by exploring “seven dimensions” for the most accurate evaluating of this symptom (Tollefson & Hillman, 2016, p. 38). The vital signs including blood pressure, heart rate, respiratory rate and temperature, with pain score and level of consciousness must be documented in observation chart (Standard 1, NMBA, 2016).
According to the NSQHS Standards (2017), the minimisation of risks and harm from hospital – acquired complications aimed to improve the quality of providing health care and enhance patients outcomes (Standard 5).
For geriatric group the risks of hospital admission include falls, nosocomial infections, malnutrition, pressure injury, mental disorders and medication complications (ACSQHC, 2018). According to the ACSQHC (2012), falls – related injuries is the major cause of morbidity and mortality in older Australians (Standard 10, p. 6). Preventing and minimising of harm from falls in this age group is highly desirable. In this case study, Mrs B has multiple risks for her health while staying in the hospital. These include pressure injury, falls risk, healthcare-associated infections (especially pneumonia), and malnutrition (ACSQHC, 2018). Assessments of these risks must be provided according to facility guidelines. For example, Mini Nutritional Assessment and Braden scale are used for evaluation of nutritional status and for predicting pressure sore risk (Standard 1, NMBA, 2016).
Nevertheless, in this case falls risk is vital for Mrs B. as she has osteoporosis and the walking ability with frame is limited due to pain and loss of muscular strength in shoulder. Such loss of strength in the proximity leads to gait instability and loss of gravity centre. Bones’ fragility, that accompanied by osteoporosis, may lead to a fracture, that may significantly prolong her staying in the hospital and stress from hospitalisation Moreover, the sleep deprivation may lead to lack of attention and confusion in unfamiliar environment, which in combination with impaired vision increase risk of falls.
In Victorian hospitals Falls Risk Assessment tool (FRAT) can be used as an assessing tool (Peninsula Health, 1999). The results of FRAT assessment indicate that functional status of Mrs B. has changed, as her ability to keep walking frame is limited. Her score put her in medium risk group. Additionally, she complains of vision problem and pain disturbance during nights, that increase the possibility of falls at this time (Standard 1.2, NMBA, 2016). The patient’s musculoskeletal issues and age indicate high falls risk (ACSQHC, 2018). Thus, the falls risk prevention plan, that reinforced with pain relief medications, must be prioritised in nursing care plan (Standard 5, NMBA, 2016).
Nursing diagnoses for Mrs B, which resulted from grouping assessment data, may include: chronic pain in left shoulder as a result of shoulder joint injury, evidenced by declining of home self-care and sleep interruptions; disturbed sleep pattern, as a result of pain appearance, which evidenced by Mrs B’s reports “being awaken during the night”; self-care deficit due to limited ability to perform bathing, toileting, dressing, as evidenced by Mrs B statement that her everyday living activity are affected by pain (Herdman T.H. & Kamitsuru S., 2014). However, effective management of risk factors in nursing care plan for falls prevention will have wider benefits for Mrs B. (ACSQHC, 2009). Hence, the nursing diagnosis for further care planning is “risk for falls” (00155 NANDA-I, (Herdman T.H. & Kamitsuru S., 2014) related to altered ability to use the walking aid secondary to pain in left shoulder, which evidenced by inappropriate usage of the walking frame and unstable gait.
According to ACSQHC, standard 10 (2012), nursing interventions for falls risk must account for many risk factors with collaboration with other members of health care team. The further falls risk assessment and prevention actions can be guided by “Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals 2009” (2012). The care plan can be complited with assessements of fear of falling, symptoms of dehydration, malnutrition and infections, and screening of balance and mobility skills. All these observation must be documented to alert responsible health care practitioner about enhanced safety requirements for Mrs B (Standard 6, ACSQHC, 2017).
The Mrs B’s nursing care plan includes following measures for prevention of falls, which correspond to her health conditions, age and support her independancy and privacy. All these reinforcements must be discussed with the client in order to achieve her safety and pain management (Standard 5, NMBA, 2016). Transferring Mrs B in a room closer to a nursing station leads to more constant observations and fastest response of personel. Orientation this older patient to a room environment and closer location of hygiene and personal items to the right side from her bed, enhances her privacy and self-care ability. At the same time, the patient’s bed must be in lowest possible heigh. Further education to use call bell and night light improves safety of Mrs B and secures that help is reachable. The Mrs B demonstrates of utilising of the call bell and nurse insures that Mrs B awares where it is located and can reach it (Standard 3, NMBA, 2016)).
Next set of action include an identification of special food requirements, rest and toilet visiting pattern, that indicate the nurse assistance in prefered by her time. Although, the patient stated night sleep disruption by pain in her shoulder, hence, nursing interractions include consultation with doctor in order to create effective pain management plan (Standard 6, NMBA, 2016). The nurse assesses medication effect on overall health condition, while checking vital signs and examination of pain scale every 2 hours or on patient demand. These data the nurse carefully notes for further evaluation (Standard 5, NMBA, 2016).
The patients outcomes include free of any falls during hospitalisation, demonstration of a call bell utilising and help requests, reduction of awakening episodes during night, and free from disturbing pain rest times .
The discharging process must include education of Mrs B to safely ambulate at home, according to Standard 3 (NMBA, 2016). For example, considering of the side of bathroom rails (ACSQHC, December 2010). In order to organase comprehensive home suppot the nurse refers to a city counsil for social worker visits. As the community nurse visits Mrs B at home, discharge letter with clinical observation must be send to a patients doctors and the community nurse (Standard 7, NMBA, 2016). Moreover, phisio exercise programs, that attends Mrs B should be changed in accirdance with limited manipulating of left arm. All these measure on discharge are supported by Standards 2, 5, 6 (ACSQHC, 2017), that aim to provide comprehansive care in collaboration with patient and other health team members.
In conclusion, individualised care for the client includes collection of data through the comprehensive assessment, planning, and implementation of essential actions to help Mrs B’s maintain her lifestyle and wellbeing. Each action considers the client’s health condition, age characteristic, and personal requirements and aided to provide the effective care in respectful manner. Further analisis of obtained clinical data and personal history based on evidance-based documents including guidelines, policies and frameworks, which support nursing practice in provision of person-centered, safe and quality care. Timely appropriate evaluation of the care plan assists in achieving the feedback from the patient, that supports both her rights and nursing professional conduct. Such partnership with the patient and collaboration with other members of health team lead to a safe and quality complex nursing care with prioritisation of patient’s needs.
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