Nursing Care Plan 1
Discuss about the Case Study Of Claudia Donaldson.
Patient-centered care approach is a necessary consideration in nursing practice, that recognizes and respects the needs of patients and their family and collaborate with them to engage in care planning (Ignatavicius & Workman, 2015). Patient centered care model respects patient’s values, needs and experiences while planning and delivering care through the use of evidence gathering in the clinical reasoning cycle. This paves the way for developing therapeutic relationship with patient and nurses (Gluyas, 2015). This report applies the principle of patient centered care to develop a care plan in relation to the case study of Mr. Davis. The care plan is developed based on the identification of two actual or potential nursing problems in the case study and the report also gives detail on patient-centered goal for each nursing problems. The justification for two nursing intervention and care plan related to each goal is also provided.
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Nursing Care Plan 1 |
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Nursing Problem 1 Mr Davis is at risk of hypovolemic shock, a condition where a patient is at risk of decreased blood volume due to blood loss either internally or externally leading to cardiac complications such as decreased cardiac output and inadequate tissue and organ perfusion. Based on the handover information, Mr Davis is at risk due to the fact that the femur receives a direct supply of blood from surrounding arteries and that the fracture will disrupt circulation both to the femur and the surrounding tissues and lower extremity. In this case study the nursing problem is potentially related to changes in the heart rate and ventricular filling capacity, as evidenced by tachycardia and hypotension and cooling of the peripheries. |
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Nursing Goals Mr. Davis will maintain appropriate cardiac output, evidenced by stabilization of systolic blood pressure and heart rate, maintenance of consciousness level and adequate urinary output. |
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Interventions with rational Intervention 1 Assess Mr Davis’s observations, including; vital signs, neurovascular and neurological, pain score and wound observations. By completing this assessment at the beginning of the shift a baseline of information is given in regards to patient’s current situation allowing for trends to be identified later throughout the shift should complication arise. It also provides the nurse with evidence to create on going observation timing requirements. Intervention 2 As Mr Davis is currently Nil By Mouth (NBM) for upcoming surgical intervention it is imperative to monitor his fluid status to ensure that he maintains appropriate hydration and cardiovascular haemostasis to maximize his ability to remain stable throughout surgical intervention and recovery. Mr Davis currently has Intravenous Therapy (IVT) running and an Indwelling Catheter (IDC) insitu which will allow for clear and concise measurement and documentation of fluid status. By regular assessment of input versus output throughout the shift, the nurse is able to determine the effectiveness of the fluid therapy and identify potential fluid overload complications. |
Expected health outcomes Health outcome 1 The major health outcome for Mr Davis by completing regular and thorough observations is the early identification of complications and the appropriate implementation of interventions as required. Based on the evidence gathered during the initial observations, the timing schedule of routine assessments will be determined. In the case study provided, Mr Davis would require regular observations at a minimum of hourly, though frequent visual status would be taken when nursing staff are available. Health Outcome 2 By the maintenance of appropriate fluid management, Mr Davis will decrease the risk of complications related to hypovolaemic shock by increasing the vascular supply. These include but are not limited to; maintenance of cardiac output which leads to appropriate perfusion of organs including the kidneys which allows for Mr Davis to preserve his ability to metabolize and excrete the medications he will receive in theatre for the surgical management of the femur fracture. |
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Nursing Care Plan 2 |
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Nursing Problem 1 Mr Davis is experiencing acute and severe pain related to injury sustained in a motor vehicle accident. Based on the handover information this is evidenced by; pain scores initially at 7/10 and currently 4/10 with PCA intervention, increased respiratory and heart rates and expressive behaviours including grimacing on movement. |
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Nursing Goals Mr Davis will experience a decreased level of pain through the use of pain assessment and pharmacological intervention; which will be evidenced by improvements within his regular observations including pain scores of a tolerable level. |
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Interventions with rational Intervention 1 An assessment of Mr Davis’ pain would be an appropriate first line intervention. This will provide a baseline for the start of the shift allowing for trends to be identified throughout. A full pain assessment should be undertaken including a “PQRST” assessment; is there pain present, quality of pain, radiation, severity and timing and also identifying the impact of the pain. By completing this assessment the nurse is able to identify and respond appropriately to current and potential pain factors. Regular assessment also provides evidence for pain relief management in the form of pharmacological intervention. Intervention 2 As Mr Davis has a PCA commenced it is important to monitor the effectiveness and appropriateness of the use of narcotic pain relief. Regular review of the PCA should be undertaken to gauge the amount of requests versus received doses to gain an understanding of his pain status. This may indicate a need for further pain relief and potential review by medical officers to address this pain. It is also important to monitor for morphine PCA associated complications such as respiratory depression, nausea and vomiting and excessive sedation. These complications can be severe considering Mr Davis’ current health status. |
Expected health outcomes Health outcome 1 Mr. Davis would be able to maintain satisfactory pain control which would decrease his anxiety, frustration or fear. Decreased pain levels allow for the patient to make clear and concise decision making, especially when it is expected that Mr. Davis will need to consent to surgical intervention which comes with its own set of risks and complications. With appropriate pain management Mr Davis will have evidenced improvement in his vital signs including stabilization of heart and respiratory rates. Health Outcome 2 The implementation and management of PCA pain relief allows for the patient to access near immediate relief when pain is present. This reduces the time frame for the patient by not requiring a nurse to attend to the bedside, complete an assessment, obtain the medications and together with another nurse complete a bedside check prior to administration. Though the PCA provides immediate relief there are safe guards implemented within the PCA protocols to minimize risk of complications such as overdosing to ensure patient safety. Whilst Mr Davis can implement his own pain relief it is important for the nurse to regularly assess the patient’s status and the PCA record hourly to ensure early identification of complications related to morphine. |
Adoption of the patient centered care for Mr. Davis is an important aspect in modern healthcare process. According to the Australian healthcare law, patient centered care helps to provide the patient with holistic care as the physical, emotional and psychological needs pf the patient are being addressed through implementation of individualized and appropriate care plans (Montori, Brito & Ting, 2014). As Mr Davis is an adult, it is important to gain his consent to involve his partner or family in the process of care planning. Further, the doctors will be able gain further understand patient’s health history, allergies and other important aspects that will help to finalise the intervention techniques and medication that will help the patient to achieve wellbeing faster. Cultural preferences, dietary requirements and ethical values are also an important aspect in person centered care therefore these should be included in the care plan. According to Einstein et al., (2014), it is possible that one intervention, which is useful for one patient, cannot provide better result in another patient due to the distress of the patient. Education and information should be provided regularly and clearly throughout the management process to allow the patient a clear and concise understanding of their health status (Doyle, Lennox & Bell, 2013). This prepares the patient mentally and physically and it becomes easier for the patient to accept the side effects as they are hopeful for their quick recovery. Further, as per the Australian nursing ethics, without the consent of patient, the healthcare professionals are unable to access the personal information, healthcare history. By involving the patient in their own care planning, medical professionals are able to ascertain these histories along with the impact they have for the patient (Montori, Brito & Ting, 2014). Nursing and Midwifery Board of Australia provide registered nurses with standards.
To promote health and recovery of Mr. Davis, it was planned to commence PC and regularly observe Mr. Davis. The main reason for implementing this intervention was to regularly check pain status of patient and assess any form of complication in patient related to PCA. This action is in relevance with NMBA standard 1 of the registered nurse standards which requires the nurse to think critically and analyze nursing practice (Nursing and Midwifery Board of Australia, 2018). By means of timely assessment process and decision making to manage pain status of patient, quality improvement in practice could be achieved. The critical reflection on managing pain by regular observation is also clinically significant decision because of its impact on Mr. Davis health outcomes considering his current health condition. The care plan can help to maintain the right dose of PCA and ensure that high quality and safe care in provided to student. Shoulders, Follett & Eason (2014) suggest that practical strategies to enhance critical thinking are important in critical care environment to improve patient outcome and improve decision making process.
Nursing Problem 1
The care plan for Mr. Davis also demonstrates comprehensive assessment of patient as per the standard 4 of NMBA standards for registered nursing practice. According to standard 4, comprehensive and systematic assessment of patient is important for registered nurse to inform care planning and priorities action for health and well-being of patient (Nursing and Midwifery Board of Australia, 2018). The care plan of Mr. Davis mentioned about conducting PQRST assessment for patient and the main advantage of such systematic assessment process was that it supported the nurse to understand all details characteristics of patient. Such steps enable nurse to implement the right intervention for patient and enhance satisfaction with care. Dansie & Turk (2013) mentions that for patient with chronic pain, comprehensive assessment assist in treatment planning and facilitating optimal outcome in patient.
Conclusion
The clinical reasoning cycle is an evidence based information gathering tool utilized by nursing staff to identify problems, establish goals, plans intervention and provides the ability to review and evaluate outcomes and reflect on the clinical scenarios. Throughout the case study it was important to utilize these steps within the clinical reasoning cycle to piece together a nursing care plan to address the identified nursing problems. Hypovolaemic shock and pain were identified as the immediate concerns for the patient. With the use of collecting cues from the handover and patient assessment, a suitable care plan was able to be devised to implement intervention and manage risk of complications. When creating this care plan its vital that the nurse understands that it’s not just physical wellbeing of the patient that is key, but knowing that overall health involves their psychological, emotional and physical health. Taking this into consideration, the nurse is able to plan and implement care that is holistic. Understanding that health encompasses more than just vital signs justifies the nurse to use their clinical reasoning to gather the information, plan and implement care that is both individual and holistic to the patient’s needs
References
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