ASSESSMENT TASK 2: Case Study Part B
Task
As this unit is not directly assessed in the clinical workplace, both assessment tasks need to reflect a simulated clinical work environment demonstrating critical thinking applied to clinical conditions.
Your research must be appropriately referenced using APA guidelinesfor each section of the care plan. This includes in-text referencing and an A to Z reference list at the bottom of the care plan. The total word limit for your responses is approximately 800. Use Times New Roman font with size 12 text.
Read the information given in the following case study and complete the following:
PART B: In consultation with your Registered Nurse, formulate a nursing care plan for Mr Smith based on his condition on 06/02/2013 as highlighted below.
Your care plan should address the steps of the nursing process and what you should be doing in each step when you are formulating a written care plan relevant to the facility.
Assessment collect data from medical record (case study), do a physical assessment of the patient, assess ADL’s, look up information about your patient’s medical diseases/conditions to learn about the signs and symptoms and pathophysiology. Determine, in consultation with your hypothetical RN, which patient conditions need to be included in your care plan.
Determination of the patient’s problem(s) make a list of the abnormal assessment data that is evident on the case study scenario and why these problems have occurred.
Nursing intervention/planning write measurable goals/outcomes and nursing interventions. Support these with a scientific rationale as to why these interventions have been put in place. This must be supported with referencing in line with the APA format.
Evaluation determine the criteria that would indicate if goals/outcomes have been met.
Case Study: Mr William Smith
William Smith is a 68 year-old man who was transferred to the Palliative Care ward three days ago from a surgical ward. He was admitted on 26/01/2013 for excision of a sacral abscess which had been causing him a lot of pain. After surgery his future management was assessed and it was decided that he would be transferred to the Palliative Care ward as he could not be discharged home.
Social History
· Mr Smith lives alone in a unit with 23 stairs. He is unable to care for himself and refuses any home help.
· According to his daughter who was contacted by the Social Worker, Mr Smith has a past history of domestic violence and abuse towards his former wife and children. His son and daughter are finding it hard to visit him even at this end stage of his life and have stated that they are not willing to care for him at home.
· Mr Smith identifies himself as an indigenous Australian (a person of Aboriginal or Torres Strait Islander descent). He was born in Arnhem Land but moved firstly to a rural township in the Northern Territory before settling in his current home in a metropolitan city at age 65 to be nearer to his estranged children.
· He has a past history of alcohol abuse until his admission to hospital on 26/01/2013.
Medical History
· Mr Smith has a past history of a primary Ca lung with liver and bone metastases.
· He also has a past history of COPD as he was a heavy smoker ( > 20 cigs a day for 45 years).
Physical Assessment on admission
· Mr Smith has dyspnoea, ascites, pruritus and bone pain (moderate to severe at times).
· He is very thin as he has been anorexic for several weeks. According to a neighbour, he lived on beer and baked beans with an occasional meal at the club when he could be taken there by a friend.
· His skin is stretched over his distended abdomen and bony prominences.
· He is not able to walk unaided further than from the bed to the bedside chair.
· He requires oxygen at all times.
29/01/2013 – Palliative Care Unit Admission Assessment
· Mr Smith is receiving regular analgesia for pain.
· He had not been ordered an aperient for several days and has not had his bowels opened since admission to hospital on 26/01/2013 and he is feeling very uncomfortable.
· He refuses to eat much as he doesn’t like the food in hospital. His fluid intake is low and he is showing signs of possible dehydration. His urine output needs to be monitored.
· Mr Smith is also complaining of stomatitis – he has poorly fitting dentures and evidence of mouth ulcers.
· He also suffers from hiccups which can last for 20 minutes at a time.
· He is complaining of nausea and vomiting. His weight loss is marked (5kg since admission 26/01/2013).
· Mr Smith can be incontinent of urine at night.
· Mr Smith is finding it very hard to sleep at night and falls asleep for long periods during the day.
· He has been talking a little about his children and speaks about his former behaviour towards his wife and children with regret. He often asks if his children are going to visit him.
06/02/2013:
Mr Smith has now been on the Palliative Care ward for a week. He has deteriorated in the past few days and is now bed bound.
· He is able to roll from side to side for PAC.
· His skin is intact apart from a small pressure ulcer (0.2 x 0.1cm) on his sacrum.
· He is extremely sensitive to soap because of an increase in ascites and consequent pruritus.
· He needs assistance with personal hygiene (sponge in bed).
· He refuses to wear his dentures now as his mouth is extremely painful. He has been ordered Nilstat and Bonjela (anaesthetic mouth gel) with limited effect as he doesn’t like the taste.
· His breathlessness has increased and he is having 4/24 Ventolin nebs.
· He is ordered soft diet, encourage fluids. Mr Smith likes ginger beer which he says helps his hiccups (next-door neighbour brought some in)
· BNO for several days. Microlax enema and Agarol 10ml given with effect.
· Can be incontinent of urine at times – pad in situ.
· Current analgesia is oral (Oxycontin 100mg bd and Tramadol 50mg bd) – Mr Smith states this regime is “holding pain at present”. Pain score 2 -3/10.
· He can be confused and agitated at times.
· Mr Smith has requested a visit from the Social Worker to try to organise a visit with his children. He is very depressed about the current situation.
· Daily TPR and BP and girth measurement.
You may wish to revise constructing nursing care plans. The following YouTube videos take nursing students through the development of nursing care plans (it is American but uses Potter and Perry’s Fundamentals of Nursing text as a reference)
Constructing a Nursing Care Plan, Introduction: Case Study
http://www.youtube.com/watch?v=ClY21HJbOTw
Nursing Care Plans | Nursing Student Guide for Nursing Care Plans (NCP)
http://www.youtube.com/watch?v=XOpT_SMLuGw
Constructing a Nursing Care Plan, Part 2: Formatting a Nursing Diagnosis/Problem Statement
http://www.youtube.com/watch?v=lCA1C1Z1F40
Constructing a Nursing Care Plan, Part 3: Developing Patient Goals
http://www.youtube.com/watch?v=yKt2zhZL9qM
Constructing a Nursing Care Plan, Part 4: Formulating Nursing Interventions
http://www.youtube.com/watch?v=il_JWCzkFfY
An example care plan template has been provided in this student study guide. You can use this template or develop one of your own.
Examples of nursing care plans can also be found in your Potter and Perry textbook:
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Crisp, J. and Taylor, C. (2009). Potter and Perry’s Fundamentals of Nursing. (3rd ed.). Sydney, Australia: Elsevier. pp. 292 – 294