Assessment And Care Plan For A Patient With Cerebrovascular Accident

Factors to consider during assessment

1a)    Identify the factors that you would need to consider prior to and during an assessment? (min 50 words)

It is required to collect information about health history such as previous health issues, incidence of previous cerebrovascular attack, any brain injury prior to assessment and during assessment it is important to consider the impairment in the vital signs and other health complications through effective neurological and physical assessment and monitoring of nutritional and electrolyte status (Ungprasert et al., 2016)

1b)       Using the information from the case study, identify and define three (3) physical or psychologically factors that will need to be implemented into Mr Bott’s care plan.

One of the main psychological factors that need to be implemented in the care plan is increasing interaction with peers in order to help Mr. Bott to cope up with the mental distress and loneliness due to the death of his wife .Another important factor should be focusing on the impaired verbal communication. In addition, effective self-care plan need to be implement in order to educate the patient regarding self-management for avoiding the risk of readmission and future health complications (Ungprasert et al., 2016).

1c)     Identify which of the following vital signs provided above are outside normal range and provide the correct range for each.

Temperature

36.5 degree Celsius which was normal as the normal range of temperature is 36.1- 37.2 degree CelsiuPulse

Pulse rate was 120 which is high as the normal pulse rate of human being ranges between 60-100 BPM

Respirations

RR was slightly high as the normal RR range is 12 to 20 BPM, however, RR under 12 or over 25 is considered as abnormal. Blood Pressure

BP was 180/90 which was high as the normal range is 120/80 to 140/ 90 mmHg.

Oxygen saturation

Oxygen saturation was 94% which was normal as the normal range of SpO2 is 75-100 mmHg, however, SpO2 less than 90% is considered as low (Tarassenko et al., 2014).

1. The registered nurse asks you to perform neurological observations on Mr Bott. Identify what data you would collect and how you would perform a neurological assessment. (min 100 words)

It is important for a register nurse to use five components of neurological assessment to collect data about Mr. Bott. For example, at first assessment of cranial nerves through complete screening of head and neck is required in order to collect data about the eye sight of the patient to identify distinct objects, movement of pupils, ability of the patient to inhale and exhale, consciousness and ability to identify odour. Next step would be examination of sensory and motor nerves through spinothalamics and dorsal .

columns to collect data about the ability of the nerves to detect temperature, touch or pain. Next process would be reflex testing through a reflex hammer to collect data about response of muscles. After that coordination testing would be done by asking the patient to touch specific body parts, move his hand and heels to understand coordination between the organs. Finally, gait test is required by asking the patient to stand or move in order to collect data about mobilization (Garner & Lennon, 2018).

1. You are now asked to complete an admission document for Mr Bott. Considering Mr Bott’s age, cultural, spiritual and religious data, identify six (6) ways in which these could be addressed in a plan of care.

Six ways include-

Ask the patient about his background, age and ethnicity.

Physical and psychological factors to implement in Mr. Bott’s care plan

Ask the family member of the patient about the background of the patient.

Recruit a language identifier who could help to identify the language of the patient and identify the cultural or social background to which the patient belongs.

Recruit a spiritual analyser who could understand the spiritual and religious background of the patient.

Recruit minimum two identifier who could identify the name, age and background if the patient………………….

Provide a ID band to the patients which contains specific information after identification of age and background (who.int, 2018)

1. As a result of the (R) sided hemiplegia, Mr Bott requires assistance to empty and change his colostomy bag. Outline the steps involved (for the nurse) to change the colostomy bag (100 words – bullet points acceptable)

Clean hand with soap and water.

Take the old pouch off gently.

Clean the skin and stoma with warm water.

Pat dry the skin.

Measure stoma with a measuring card.

Trace the measurement on the skin barrier.

Cut the measurement on skin barrier with ostomy scissors.

Apply barrier ring around the stoma.

Ensure that the ostomy pouch is sealed by using Velcro snap or clip.

Apply the new skin barrier on the stoma and press down all the edges (Timmermans et al., 2014).

5a)    Outline 3 risk factors associated with immobility, providing a brief explanation of each one chosen. (Bullet points are acceptable when accompanied by an explanation (100 words

Osteoporosis- It is condition in which people lacks muscle strength and endurance and the bones loss mass hence becomes weak. The patient fails to provide adequate pressure on bone, thus, they face difficulties during mobilization.

Stroke- It is an acute neurological event which has functional and physical effects that leads to the consequence of chronic disability due to severe neurological impairment.

Arthritis- The disease mainly affect the joints which leads to inflammation and muscle pain and restricts the movement of the patient (Engbers et al., 2014).

5b)    Which assessment tool will need to be completed before Mr Bott is moved? (50 words)

As Mr. Bott has been suffering from the issue of immobility it is important to complete the assessment associated with risk of fall. In this regards the Banner mobility assessment tool may be helpful (Boynton et al., 2014).5c)     Mr Bott has agreed to sit in his chair for lunch. Identify six (6) factors that the nurse will need to consider before assisting with mobilisation. (150 words – bullet points acceptable only when accompanied with a brief explanation of each).

Six major factor that need to be considered while assisting the patient with mobilization include-

The nurse needs to ensure that the patient has adequate strength and self-determination to move and sit in his chair for lunch.

Next the nurse should position the bed which could help the patient to get out easily.

The nurse should be prepare and stand in a comfortable position to support the patient during rising up from the bed.

The nurse should communicate throughout the [process and guide the patient during rising up from the bed.

After such preparation the nurse could allow the patient to move and sit on the chair for lunch (Filipek, Redlich & McLeod, 2018)

6b)    Provide 4 examples of ways in which the nurse can promote Mr Bott’s dignity and independence during his lunchtime meal. (Each point must be accompanied by an explanation 100 words) 

Vital signs outside the normal range

The nurse should ensure that the patient has received adequate support during the lunchtime meal in order to make him feel dignified.

It is important to allow the patient to choose food that he desired to intake without restriction in order to make him feel independent.

The nurse could allow the patient to choose a comfortable place to sit for the meal.

The nurse could engage the patient in conversation and take feedback regarding the food and allow him to respond freely (Matiti, 2015).

7a)    During the afternoon, Mr Bott indicates that he wishes to lie down. Once Mr Bott is lying down you notice that his right heel is red and non-blanching.

Identify a type of screening assessment, commonly used in the prevention and management of pressure injuries. Provide a brief explanation of the assessment tool you have chosen.

One of the effective tool in screening pressure injury is the comprehensive skin assessment tool. The tool is employed in order to identify the skin damage such as the surrounding parts and helps to protract the risk of development of pressure ulcer or other pressure injury, hence helps to provide effective recommendation according to the condition of the skin (Edsberg et al., 2016).

7b)    What are the extrinsic and intrinsic factors that cause (or contribute) to the formation of pressure areas/decubitus ulcers? (50 words)

Extrinsic factors- immobility, lying on a surface for long time with same position,age of the patient, patient with mental disorder may fail to identify the discomfort as a sign of changing position, thus could develop pressure ulcer and incontinence also causes pressure ulcer due to skin damage.

Intrinsic factors- Poor nutrition status, poor blood flow and neuropathy or other condition associated with poor sensation (Edsberg et al., 2016).

7c)     Present a list of strategies specific to Mr Bott’s care, to prevent further pressure injury. (50 words)

Proper inspection of skin

Prevent friction

Change position on bed frequently.

Reduce the level of moisture

Apply appropriate barrier cream.

Provide adequate nutrition (Edsberg et al., 2016)

7d)    Discuss whether or not the indication of a pressure injury would require you to collaborate with any other health professional. In your answer, provide details of the text within the Enrolled Nurse Standards for Practice which directly relates to decision making. (100 words)

The standard 5 of NMBA standards of practice for enrolled nurse indicates that it is important to collaborate with RN in order to develop effective care plan and standard 6 indicates the importance of skilled and timely care and involve in effective decision making. Hence ot is important to collaborate while identifying the risk of pressure injury for provided effective care and make proper decision regarding the care plan (nursingmidwiferyboard.gov.au, 2018).

7e)    Provide an example of a progress note entry for your client to indicate the presence of the new pressure injury to the right heel, include any strategies you have put in place to prevent further injury (50 words)

21/10/2018

9:00 NURSING: Mr. Bott expressed some injury at the right heel. Some education concerning how to regulate the condition was given. Body positioning was done to lessen the impact of the injury. In addition, recommendations for changing the dietary habits have been provided which would be helpful in this

8a).   What is the nurse’s role in the discharge planning of Mr Bott?  In your answer include:

• when the discharge planning process should commence
• the members of the multidisciplinary team that should be involved
• any community services he may require

(min 100 words) 

Nurse plays an important role in the discharge planning as they helps to ensure the successful outcomes of the treatment through effective assessment. Before discharging a patient the nurse complete necessary documentation regarding the health of the patient and help the patient to learn about the self-management after getting discharge. The nurse communicates with the multidisciplinary team and collect recommendation from each member regarding the maintenance of health and well-being of the patient. Further, the nurses inform the patient regarding the effective community service which may help him to access home based care as well (van et al., 2015).

8b)    Being unwell and receiving care for even a period of time can result in increased risk and complications to the client. Provide 4 examples of those risks or complications. (50 words)

Receiving care for a long time in hospital may increase several health risk for example, it may increase the level of stress, increase the risk of hospital associated infections, increase the risk of medication error and disappointment of the patient due to prolong treatment may affect the recovery process (Moore et al., 2017).

9)      After 5 weeks on your ward Mr Bott is preparing to be discharged when his condition deteriorates. You come onto the night shift and in handover hear that Mr Bott is unwell. He is febrile at 38 degrees and has IV hydration in progress. Mr Bott’s fluid input and output are being monitored. Mr Bott’s right heel has now broken down and he has been complaining of pain when he coughs.

You approach the bedside to review your client. Discuss at least 6 factors that you will you need to consider at the beginning of your shift. Include an explanation of why with each? (150 words bullet point list is acceptable)

First, it is important to consider the care process before the shift in order to understand the health requirement of the patient.

Second, it is important to monitor the IV hydration.

Third, it is required to monitor the status of fluid input and output to identify any problem associated with fluid intake.

Fourth, it is important to check the vital signs to identify any impairment associated with the current health condition.

Fifth, it is required to check the temperature for providing the medication to reduce the temperature.

Finally it s important to assess the pain level of the patient in order to provide effective nursing strategies.

10a)  Mr Bott has developed a chest infection, he slowly and with difficulty explains to you that he does not wish to take antibiotics and wishes to be left to die in peace. Evaluate the role of the nurse in this situation, including the legal aspects of refusal of treatment. (200 words)

If Mr. Bott refuses to take antibiotics and other treatment it is the duty of the nurse to communicate with him and identify the reason behind such decision. Then the nurse needs to encourage him to continue treatment while informing him about the effectiveness of treatment and induce hope for recovery. However, the patient has right to refuse treatment and it is the duty of the nurse to honour the rights of the patient. On this case the nurse could communicate with the patient or with the family members and relatives to take proper decision regarding the treatment and take valid consent for proceeding with the treatment (Brazier & Cave, 2016)……

10b) In January 2016, The Nursing and Midwifery Board of Australia published a new Standards for practice for enrolled nurses. From this document, identify the most applicable standard relating to client rights. (25 words).

The most applicable standard related to the client rights is standard 2 which provide guidelines about Practises nursing in a way that ensures the rights, confidentiality, dignity and respect of people are upheld (nursingmidwiferyboard.gov.au, 2018)..

PART B – Care Plan

1a)    Identify and name the National Safety and Quality Health Service Standard which focuses on responding to clinical deterioration (25 words)

The standard 9 of National Safety and Quality Health Service which provides evidence based strategies for Recognising and responding to clinical deterioration in acute health care focuses on responding to clinical deterioration (safetyandquality.gov.au, 2018)

1b      How will an enrolled nurse make sure that any new information or changes in the required treatment or care of a client are recorded and implemented into the client’s care plan? (25 WORDS)

Effective documentation of the health condition of the patient and monitoring the patient and comparing the previous and new care plan would help a enrolled nurse to ensure that required treatment is included in the care plan (O’brien et al., 2015)…1c)     You have monitored Mr Bott’s care plan and in consultation with the registered nurse, the pressure injury to the right heel is added to the care plan below. A week later, there is no further evidence of breakdown and the redness on the right heel has reduced. Complete the evaluation by adding at least 3 additional points

Sample care plan:

Assessment	Nursing Problem	Goals/Expected Pt Outcomes	Intervention	Evaluation
Subjective data: Decreased mobility Objective data: Redness to right heel	Impaired Skin Integrity Stage 1 superficial pressure injury, indicated by non-blanching, redness that does not subside after pressure is relieved	Within 2 weeks Clean intact skin Pressure relief is provided by position change and pressure relieving mattress Nutritional intake is appropriate	Pt will be turned and /or positon changed every two hours as evidence by nursing documentation Mobilise twice daily (as per mobility care plan) Conduct a full skin inspection twice daily paying close attention to the skin directly over bony prominences Bed linen to be kept clean and wrinkle free Reduction of moisture to the skin Monitor nutritional intake with a daily food chart Offer hourly fluids whilst awake Use manual handling aids to prevent friction and sheering Use sheepskin boots for comfort and to reduce sheer	By the end of day 7 there is reduced redness over the right heel. Improvement in the mobility has been noted. Improvement in the electrolyte and nutrient balance have been found. The risk of severe infection due to pressure injury has reduced.

CASE STUDY 2

Ella is a 6-year-old girl who has cerebral palsy who had been brought into hospital with a chest infection. You have been asked to perform a health assessment for Ella who is distress at being in hospital.

Cerebral palsy can cause different degrees of developmental delay but in order to understand the impact the condition has on a person you need to be aware of the stage of growth and development a person should be at.

1)      Discuss the stage of human growth and development that you would expect Ella to be at as a six-year old? (min 100 words)

At age 6, the sense of body image starts to develop within human beings. At this age the children become able to speak complete sentence with seven or more words and also show faster growth of mental ability. They starts to read books and become able to decode unfamiliar sound and words. As physical development the milk teeth starts to replace by permanent teeth, they grow 2.5 inch and 4-7 pounds a year and approximately their weight should be 45 pounds and height should be 45 inches at this stage. However, due to several health issue impairment in growth may occur (Trevathan, 2017).

2a)    Refer to the Person Centred Health Care Assessment and the Development of Health Care Plans Core Standards for Practitioners to answer this question.

Identify at least six (6) potential health issues associated with cerebral palsy.

Six major health issues associated with cerebral palsy include-

Delay in speech.

Difficulty in walking.

Lack of coordination of muscle which is known as ataxia.

Drooling.

Sleeping issue.

Several neurological issue such as blindness, intellectual disabilities and seizures (Wright et al., 2018).

2b)    List the four (4) essential skills that you need to draw upon when completing a health care assessment on Ella?

As Ella has been suffering from cerebral palsy it is required to use assessment which would be comfortable for her. In this regards it is important to have several nursing skills such as-

Effective communication in order to interact with the child so that she could share her problem without any hesitation.

Nursing diagnosis and care in order to identify the central issue of the child and introduce effective care plan.

Advocacy in order to advocate regarding the health needs and provide adequate health resources to meet the needs of the patient.

Competency in order to understand the condition of the patient and use appropriate way of conducting health assessment with confidence for involving the patient in the assessment effectively (Jho, 2014).

2c)    Identify at least six (6) components of a comprehensive care health plan and provide the reasons why they are included in a person’s plan?

Six components of health plan include-

Assessment- To collect adequate data regarding the health condition of the patient.

Nursing diagnosis- To identify the health issue and responsible factors in order to address them and help the patient to recover.

Expected outcomes identification- To identify the nursing goals and their particular outcomes.

Planning- To include effective care approach and treatment according to the identified health issue of the patient.

Implementation- Implement the care plan in an effective manner in order to achieve desired outcomes.

Evaluation- In order to identify the effectiveness of the treatment, identify the improvement or deterioration in health and introduce further care plan as per the requirement (Wager, Lee & Glaser, 2017).

In order to reduce distress it is required to provide first priority to the physical comfort of Ella. On the other hand it is important to talk with her throughout the assessment to make her involve with the assessment. In addition she could be teach regarding relief techniques such as taking slow and deep breaths. Further, she could be provided toys, chocolate or offer a treat and could be allowed to listen music in order to employ distraction (Wager, Lee & Glaser, 2017). Such strategies could help the nurse to introduce calmness and reduce the distress of the patient

You speak with Ella’s mum, Karen, who is staying in hospital with Ella and she tell you that their family like to take a wellness approach to health. 

4)      Explain what a wellness approach to health means and provide at least 3 examples of how a wellness approach could be used for Ella. (min 100 words)

Wellness approach to health is define as the approach that helps to deliver health care with multiple influences such as physical, mental, cultural, spiritual and environmental influence on health. It focuses to treat, prevent illness and promote health practice to optimize the well-being, hence, besides adding some effective health practice it also removes some factors which may interfere with the normal health function. In this regards Ella could be encouraged to practice healthy eating habit and proper diet with adequate nutrients, she could be motivated to practice some physical activities and she could be taught to communicate and engage with other children and family members. It could help her to improve both physical and mental well-being (Hood, Lovejoy & Price, 2015).

5)      As a family with a young child, identify some of the family health care needs that Ella and her family may require. (min 50 words)

The family healthcare needs may include health education to learn about primary home based care, health promotion program to understand different health issues and the prevention plan, access to health resources to utilise them during the time of need and social and medical support to maintain the well-being (Hood, Lovejoy & Price, 2015

6)….. When checking Ella’s vital signs one afternoon you note that her respiratory rate has increase from 22 to 32 and that her SpO2 has decreased from 98% to 92%. Identify what actions you would take. In your answer, discuss the following:

• who you would inform of Ella’s condition
• what clinical signs suggest that there is a deterioration in Ella’s condition. (min 50 words)

The clinical signs such as elevation in respiratory rate indicates the high struggle of heart to get adequate oxygen and compensate and low oxygen saturation indicates the poor intake of oxygen which may increase the breathing issue during chest infection and could create life threatening situation. Hence, it is important to inform about such deteriorating sign to the senior nurse and the doctor who has taken responsibility of the patient (Tarassenko et al., 2014).

2)      Discuss the impact of infertility on Sandra. In your answer ensure that you cover the physical, emotional and psychosocial impacts. (min 100 words)

The consequence of infertility could impact negatively on the physical, emotional and psychosocial aspects of Sandra. For example, due to infertility, declination on health status may be observed along with weight loss, weakness and emaciated body. On the other hand, the condition could lead to the consequence of severe depression and anxiety due to disappointment and lack of hope, which may affect her peace of mind, thus, reduce the ability to interact with people. Together the physical and psychological issues may reduce the ability to involve in the daily activities (Kazemijaliseh et al., 2015). Due to such condition Sandra may fail to maintain relationships and due to lack of engagement with society she may suffer from social isolation as well…

3)      When talking to Sandra about her family, she mentions that her son, Dean, has been very moody lately and is difficult to talk to. What information about adolescent growth and development could you share with Sandra? (min 100 words)

It is important to understand about the factors associated with growth and development of adolescence to understand their condition and use effective ways to interact with them. Sandra could be informed about the physical changes such as muscular development, changes in voice, appearance and development of sexual organs. Along with such physical changes several psychological changes also occurs such as changes in thoughts and desire towards ladies. Hence, it is important for Sandra to consider the state of mind of her son and communicate with him without restricting for all things, but with mutual understanding of thoughts and she needs to provide sexual education to her son so that he could understand the reason of such changes and become accustomed with the condition (Steinberg et al., 2015).  ..

a’s son visits, you notice that he is physically very similar to his mother, they both have red hair, blue eyes, freckles and both are tall.

Discuss the influence of both genetics and the environment on growth and development. (min 100 words)

Both the environmental and genetic factors play an important role in dictating how the human organism shall be. In relation to environment it has been found that different factors such as chemical, radiation, climate and other surroundings impact on the DNA which is responsible for the development of various cells, tissues and organs (Carlson, 2015). On the other hand, genetics is the basic element through which the human characteristics are inherited from the parents to their children (Cobb, 2016). Hence, in case of Sandra’s son the chromosomal transference of parental genes has resulted in the similar physical characteristics with his mother.

References:

Boynton, T., Kelly, L., Amber Perez, L. P. N., & Miller, M. (2014). Banner mobility assessment tool for nurses: instrument validation. Am J SPHM, 4, 87.

Brazier, M., & Cave, E. (2016). Medicine, patients and the law. Oxford University Press. 2^nd edition. pp. 32-67.

Carlson, D. S. (2015). Evolving concepts of heredity and genetics in orthodontics. American Journal of Orthodontics and Dentofacial Orthopedics, 148(6), 922-938.

Cobb, M. (2016). Genetics: On the heredity trail. Nature, 533(7602), 178

Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing, 43(6), 585.

Engbers, M. J., Blom, J. W., Cushman, M., Rosendaal, F. R., & van Hylckama Vlieg, A. (2014). The contribution of immobility risk factors to the incidence of venous thrombosis in an older population. Journal of Thrombosis and Haemostasis, 12(3), 290-296.

Filipek, C., Redlich, M., & McLeod, S. (2018). An innovative mobilization framework for delirium management: Howto un-paralyze the assessment and implementation process. Canadian Journal of Critical Care Nursing, 29(2).

Garner, J., & Lennon, S. (2018). Neurological assessment: the basis of clinical decision making. Neurological Physiotherapy Pocketbook E-Book, 55.

Hood, L., Lovejoy, J. C., & Price, N. D. (2015). Integrating big data and actionable health coaching to optimize wellness. BMC medicine, 13(1), 4.

Jho, M. Y. (2014). Effects of core fundamental nursing skills education on self-efficacy, clinical competence and practice satisfaction in nursing students. Journal of Korean Academy of Fundamentals of Nursing, 21(3), 292-301.

Kazemijaliseh, H., Tehrani, F. R., Behboudi-Gandevani, S., Hosseinpanah, F., Khalili, D., & Azizi, F. (2015). The prevalence and causes of primary infertility in Iran: a population-based study. Global journal of health science, 7(6), 226.

Matiti, M. R. (2015). Learning to promote patient dignity: An inter-professional approach. Nurse education in practice, 15(2), 108-110.

Moore, B. J., White, S., Washington, R., Coenen, N., & Elixhauser, A. (2017). Identifying increased risk of readmission and in-hospital mortality using hospital administrative data. Medical care, 55(7), 698-705.

nursingmidwiferyboard.gov.au (2018). Nursing and Midwifery Board of Australia – Enrolled nurse standards for practice. 

O’brien, A., Weaver, C., Hook, M. L., & Ivory, C. H. (2015). EHR documentation: the hype and the hope for improving nursing satisfaction and quality outcomes. 

Steinberg, L., Dahl, R., Keating, D., Kupfer, D. J., Masten, A. S., & Pine, D. S. (2015). The study of developmental psychopathology in adolescence: Integrating affective neuroscience with the study of context. Developmental Psychopathology: Volume Two: Developmental Neuroscience, 710-741.

Tarassenko, L., Villarroel, M., Guazzi, A., Jorge, J., Clifton, D. A., & Pugh, C. (2014). Non-contact video-based vital sign monitoring using ambient light and auto-regressive models. Physiological measurement, 35(5), 807.

Timmermans, L., Deerenberg, E. B., van Dijk, S. M., Lamme, B., Koning, A. H., Kleinrensink, G. J., … & Lange, J. F. (2014). Abdominal rectus muscle atrophy and midline shift after colostomy creation. Surgery, 155(4), 696-701.

Trevathan, W. R. (2017). Human birth: An evolutionary perspective. Routledge. 3^rd edition. pp. 21-78.

Ungprasert, P., Wijarnpreecha, K., Koster, M. J., Thongprayoon, C., & Warrington, K. J. (2016, December). Cerebrovascular accident in patients with giant cell arteritis: a systematic review and meta-analysis of cohort studies.  46 (3), pp. 361-366.

van Sluisveld, N., Hesselink, G., van der Hoeven, J. G., Westert, G., Wollersheim, H., & Zegers, M. (2015). Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge. Intensive care medicine, 41(4), 589-604.

Wager, K. A., Lee, F. W., & Glaser, J. P. (2017). Health care information systems: a practical approach for health care management. John Wiley & Sons. 3^rd edition. 55-235.

Wright, F. V., Lam, C. Y., Mistry, B., & Walker, J. (2018). Evaluation of the reliability of the Challenge when used to measure advanced motor skills of children with cerebral palsy. Physical & occupational therapy in pediatrics, 38(4), 382-394.