Introduction:
According to The Department of Health (2009) care planning is essentially about addressing an individual’s full range of needs. It takes into account their personal, social, economic, educational, cultural and mental health needs. After initially discussing this assignment with John (patient) and the Clinical Nurse Manager both parties agreed that the author could proceed. All information will be kept confidential and no names will appear on this assignment that could be traced back to the client or hospital. As a student nurse this will comply with the guidelines set out by An Bord Altranais (2009). All nurses should be able to account for the care they give, why they give the care and also an evaluation of the care they have given. Barett et al (2009) maintain that this is a core part of care planning.The Department of Health and Children (2001) has shown its commitment to organising care plans and the importance of them as was evident in the 'Primary Care A new Direction' health strategy.This identified the importance of discharge planning and and the development of individualised care plans following discharge. This assignment will cover a full assessment of a person whose care the author has managed in the clinical setting. Based on this assessment the author will compile a care plan focusing on two key nursing diagnoses derived from the nursing assessment. The author will list all nursing diagnosis related to this patient and give a rationale for each.
John Reynolds is a 56 year old gentleman admitted to the ward through the emergency department. He fell off a ladder at home whilst cleaning his chimney. He fell approximately 8-10 feet onto concrete. He had sudden pain to his left leg and this remained the...
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...tein, G. and Stubhaug, A. (2008). Assessment of pain. British Journal of Anaesthesia. 101 (1), pp 17-24.
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Ackley, B. J. and Ladwig, G. B. (2010) Nursing Diagnosis Handbook. An evidence based guide to planning care (9th Edition). Philadelphia: Mosby Elsevier.
An Bord Altranais (2007) Guidance to Nurses and Midwives on Medication Management. (http://www.nursingboard.ie/en/policies-guidelines.aspx) (accessed 15th October, 2011) (Internet).
A 49 year old man who goes by the name of Martin was admitted into hospital with fractures in his left tibia and fibula and clavicle that he endured from a motor accident he was involved in. It is reported that there was a total of 146,322 personal injury road traffic accidents in the UK in 2014. (Department for Transport 2015). Surgery has been scheduled for Martin within the next day or two to fix the fractures he received in the accident; he is in a lot of pain. A fracture is to break a part, especially a bone (Weller, Pratt, and Barbara F 2014). Martin also mentioned that he has been feeling stressed recently from working a lot of overtime he is the bread winner in his home. In order to meet Martins health needs, provide person centered care and a range of services, a variety of professionals from the multidisciplinary team will be involved in his care delivery using a model of care (Roper-Logan-Tierney Model of Care 1996).
The goals and objectives set out in the policy and subsequently analysing one aspect of the policy in particular are included. How patient care and nurses delivery of said care is improved by this policy.
Ackley, B. & Ladwig, G. (2010) Nursing diagnosis handbook:an evidence based guide to planning care. Maryland Heights, MO: Mosbey.
...amount of pain) is a great teaching tool for the patient who is able to self-report (Nevius & D’Arcy, 2008). This will put the patient and nurse on the same level of understanding regarding the patient’s pain. The patient should also be aware of the added information included with the pain scale: quality, duration, and location of the pain. During patient teaching, it should be noted that obtaining a zero out of ten on the pain scale is not always attainable after a painful procedure. A realistic pain management goal can be set by the patient for his pain level each day.
St. Louis, MO: Elsevier Ackley, B.J., Ladwig, G.B., & Flynn Makic, M. (2017). Nursing diagnosis handbook (11th ed.). St. Louis, MO: Elsevier University.
On 2/9/18 I met Mr. Mossman at the office of Dr. Drayer. Travel time was extended due to several winter weather. Mr. Mossman’s last day of therapy is today. Dr. Drayer has a physical therapist in his office that will perform measurements before. Dr. Drayer does his evaluation. Per the physical therapist, the range of motion and strength has dramatically improved since the last office visit. Dr. Drayer was very happy with the progress. He told Mr. Mossman to do whatever is able to do, that he will not hurt the repair. Mr. Mossman denied any pain at all. He has been released to full duty work as of 2/12/18. There are no further follow up appointments.
The steps in the nursing process relate to evidence based practice in many ways. During the diagnostic, and assessment steps of the nursing process important clinical questions are considered and the critical review of existing knowledge is completed. Evidence based practice also begins with identification of the problem and knowing the clinical problem by asking questions, in relation to the nursing process. These clinical questions are asked in a concise, accurate, and organized way which allows for clear answers. Once all the specific questions are identified, the second step is to search for evidence by an extensive research of the best information to answer the question. The third step in the nursing process is to develop a plan of care. In evidence-based nursing practice, the plan of care is established upon completion of a critical research of what is known and not known about the specific problem. Next in the traditional nursing process, the nurse implemen...
The following case study report focuses on the planning of care from case study part A. Emily was an eight year old girl living with two chronic and complex illnesses; type 1 diabetes mellitus (T1DM) and Crohn’s disease (CD). The importance of guiding principles delivered by the registered nurse (RN) used to plan nursing care within the health care setting will be defined and examples will be given that relate to Emily and her experience. A discussion of the overall role of the RN in the management of a patient with chronic and complex conditions will be explored and an analysis of how the RN collaborates with the interdisciplinary team to coordinate comprehensive nursing care will also be determined and subsequently examined.
Firstly, nurses are expected to practice evidence-based health care hence a mastery of information about the essential and safe dose of drugs for a patient is very important for a nurse. Consequently, it could be the determinant between the life and the death of the patient. Pharmacology is a discipline which is mandatory for the nurse to excel in to be efficient in discharging his/her duties. Understanding which drug to use, the right dosage, the expected side effects which may occur and the contra-indications of the various drugs are key in the preservation of
Dougherty, L. & Lister, s. (2006) ‘The Royal Marsden Hospital manual of Clinical Nursing Procedures: Communication 6th Edition Oxford: Blackwell Publishing Ltd
The patient is a 27 year old male who came in the hospital with pain and swelling in his left ankle. He had said he jumped off a porch and landed on a root. A three view ankle x-ray was ordered. The doctor found that there was an oblique spiral fracture of the distal one third diaphysis of the tibia. There is approximately 1 centimeter of lateral displacement of the distal fracture fragment with respect to the proximal fragment. Spiral fracture is caused by a twisting force. The result is a spiral-shaped fracture line above the bone, like a staircase. Depending on how much force causes the fracture, spiral fractures can be displaced or stable. A displaced fracture is when the broken ends of the bone are separated. Stable fractures happen when
Haugen, N., Galura, S., & Ulrich, S. P. (2011). Ulrich & Canale's nursing care planning guides: Prioritization, delegation, and critical thinking. Maryland Heights, Mo: Saunders/Elsevier. 14
Spark Ralph, S. & Taylor, C. M. (2011). Nursing diagnosis reference manual (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Gordon, M. (2007). Manual of nursing diagnosis: including all diagnostic categories approved by the North American Nursing Diagnosis Association (11th ed.). Sudbury, Massachusetts: Jones and Bartlett.
Potter, P. A., & Perry, A. G. (2009). Fundamentals of nursing (Seventh ed.). St. Louis, Mo.: Mosby Elsevier.