Category: Nursing Care Plan

Nursing Care Plan for Patients with Edema

The patient being discussed in this nursing care plan will be referred to as Mrs. Eileen Sparks. She is 80 years old, of German decent, speaks very little English, and currently resides in the Richmond, Vancouver area. Mrs. Spark’s husband, Ian Sparks, died five years ago. They had met in Berlin and immigrated to Canada in their late 20’s. They had one son named Robert, who currently resides in North Vancouver.

Mrs. Sparks was admitted to the hospital on September 4th, 2019 for acute back pain, secondary to a lumbar fracture sustained during a fall that was left untreated. Her health history includes: cataracts, hyperthyroid, hypertension, gastric esophageal reflux disease, psoriasis, shingles, and aortic stenosis. Allergies include: ciprofloxacin, penicillin, acetaminophen/codeine, and tetracyclines. The patient was on a soft diet with fluids. According to PT and OT assessment, Mrs. Sparks was a two person assist from the bed to sitting position and from sitting to standing position, as well as a two person assist with a walker. When mobilizing the patient, it was noted that her leg strength and range of motion was quite limited, and she had difficulty understanding how to use the walker effectively. This posed challenges regarding mobility and fall risk. Due to her back injury, any movement (rolling in bed, laying down in bed from a sitting position, etc.) caused her a lot of pain. In turn, she was taking opioid analgesics. Opioids reduce nervous system activity and slow muscle contractions in the gastro-intestinal tract (GI tract) which results in the intestinal walls absorbing more fluid (Rausch & Jansen, 2012). Additionally, movement is one of the body’s natural mechanisms of moving food through the GI tract (Bodian, 2019). In turn, her pain level and lack of movement, combined with the side effects of opioid treatment, resulted in incontinence of urine and constipation.

During the patient’s head to toe assessment, vital signs were stable. Respirations were found to be easy and regular. A heart murmur could be heard at the pulmonic area, commonly heard in those diagnosed with aortic stenosis (Alpert, 1990). Capillary refill was less than three seconds bilaterally in both feet and hands. Dorsalis pedis pulses were strong bilaterally. Bowel sounds were heard in all four quadrants of the abdomen. Abdomen was slightly distended, but soft when palpated. When examining the patient’s legs, swelling was noticed in the left calf. When palpating the swollen area, grade two pitting (3-4 mm rebound in 15 seconds) was noted in the left calf. The circumference of the calves was measured halfway down the length of the calves. The left calf was found to be 20”, while the right calf was 17”. The left calf was hot to the touch and the patient complained of non-radiating pain, rated 4/10 on a pain scale, when palpated. No heat or pain was noted in the right calf. Patient reported that a pain level of 2/10 would be tolerable in her calf. Edema is caused by an increase in hydrostatic pressure. In those with heart failure or high blood pressure, the heart muscles can be remodelled resulting in harder, thicker tissue that is less effective at pumping blood around the body. This leads to decreased renal perfusion, followed by an increase in renin and aldosterone production, which ultimately causes the body to retain more sodium and fluid (Pellicori et al., 2015). Mrs. Sparks reported an overall pain level of 8/10. Her ability to remain coherent while in so much pain showed extreme resilience. Mrs. Sparks did not say much to anyone as there was a language barrier present. She napped for most of the day and seemed in the greatest of spirits when her son came to visit once a week. Once discharged, she planned to move in with her son and have daily home supports.

Based on the patient’s health history and assessment, the nursing diagnosis this care plan will focus on is: Actual increased fluid retention, (secondary to hypertension and heart failure), related to lack of mobilization, evidenced by bilateral pitting, tenderness, and heat and pain localized in the left calf. This diagnosis was prioritized because peripheral edema is a sign of reduced cardiac output (Pellicori et al., 2015), and it is important to try and get blood pumping more effectively back to the heart. Additionally, it was a discomfort for the patient and comfort is always something that should be prioritized.

There are many interventions that can be used to try and reduce fluid retention. The first being pharmacological interventions. The use of diuretics and angiotensin converting enzyme inhibitors (ACE inhibitors) are first line treatments for patients presenting with peripheral edema, especially due to heart failure. Loop diuretics (e.g. Lasix) inhibit the reabsorption of sodium and fluid in the loop of henle, thus decreasing retained fluid. Thiazide diuretics and mineral corticosteroid receptor antagonists are also commonly prescribed in combination as well. ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II, thus decreasing the amount of circulating aldosterone which leads to the excretion of fluid and sodium (Pellicori et al., 2015). Mrs. Spark was prescribed Lasix and Lisinopril by the hospital physician. Providing these medications to the patient as prescribed in the medication administration record will be a very important intervention in helping to reduce fluid retention. A review by Pellicori et al. (2015), found that 25% of patients have difficulty adhering to a medication schedule. As Mrs. Sparks will most likely have to continue taking these medications once discharged from the hospital, education regarding the importance of taking the medication, as well as side effects and interactions to be aware of will be a necessary step of this intervention. Due to the language barrier, this will include educating Mrs. Sparks’ son or having Mrs. Sparks’ son translate the importance of drinking lots of fluids to reduce the chance of dehydration and constipation, reporting symptoms of hypokalemia (i.e. constipation, arrhythmias, muscle weakness, fatigue), and to refrain from taking non-steroidal anti-inflammatories (Redman, 2019).

The second intervention is compression therapy. Compression stockings apply pressure to the legs preventing the buildup of fluid and reducing inflammation (Alguire & Scovell, 2019). They should be applied in the morning in order to prevent buildup of fluid throughout the day, and taken off before bed. Stockings should be properly fitted. They do have the potential to cause tenderness and pain. If this is the case, they can instead be put on before the patient wants to walk around, or sit in their chair. A stocking donner could also be used if the patient has trouble putting the stockings on themselves (Sterns, 2019). If stockings are not tolerated, stretchable bandages (Simon, 2014) and pneumatic compression devices (Trayes et al., 2013) are alternative forms of compression therapy that could be used. Compression stockings acts as a good long-term intervention as they can continue to be used upon discharge (Simon, 2014). However, compression therapy can be contraindicated in patients with heart failure. In turn, it will be important to ensure the ankle-brachial index is less than 0.7 (Simon, 2014)., and consult with the physician before initiating.

The third intervention is elevation. Elevation can be achieved by placing a few pillows under the patient’s legs or by raising the foot of the bed so the legs are above heart level. Elevation allows gravity to naturally move fluid from the legs, back into systemic circulation (Procter, 2018). According to Sterns (2019), this has been proven to be an effective treatment to reduce peripheral edema when performed for 30 minutes, four times a day. When Mrs. Sparks is in bed, her legs should be elevated above her heart as much as possible.

The fourth intervention is exercise. Walking is the body’s way of stimulating the skeletal muscle to move blood from the lower extremities back to the heart. This reduces venous congestion, as well as any fluid pooling that has occurred (Alguire & Scovell, 2019). Working with PT and OT, it will be important to help Mrs. Sparks mobilize at least twice a day with her walker in order to get her blood circulating. As Mrs. Sparks can be resistant to mobilizing, it will be important to educate her on the therapeutic effects movement and exercise have on reducing the swelling in her legs and ultimately, helping improve her cardiac output.

The fifth intervention is diet. Sodium binds to water in the body and in turn, increased sodium can result in fluid retention. It is beneficial for patients suffering from hypertension and heart failure to eat a diet that is moderate in sodium (Pellicori et al., 2015). While in the hospital, Mrs. Sparks will be receiving meals planned by the dietician. However, education should be provided regarding the importance of a low sodium diet, and foods that are high and low in sodium.

The sixth intervention is foot massage. A study by Coban and Sirin, as referenced by Simon (2014), found that in a controlled trial, a test group who received 20-minute foot massages for five consecutive days saw reduced leg circumference compared to the control group. They stated that, “the manipulation of soft tissue foot massage moves extravascular fluid without disturbing intravascular fluid.” (Simon, 2014, p. 9). In turn, a 20-minute foot massage should be given to Mrs. Sparks once a day.

The final interventions involve monitoring the swelling and performing regular pain assessments. Mrs. Sparks’ edematous tissue was radiating heat. She complained that it was tender to the touch and rated the pain level at 4/10. In turn, it will be important to assess her pain level and potentially administer PRN acetaminophen if deemed appropriate. Additionally, it will be important to monitor for increased/decreased fluid retention. This can be achieved by measuring the circumference of the calves (halfway down the length of the calf) at the start of each shift and comparing to previous measurements. This will allow you to know if the interventions are working and/or if the swelling is getting worse.

An example of the implementation of the nursing care plan is as follows:

Time / Nursing Action

07.00-07.15 / H/T assessment (including measurement of calves, & pain assessment)

07.15-07.20 / Put on compression socks and elevate the legs with pillows – Opportunity to educate on the importance of elevation in reducing swelling

08.00-08.15 / Administer meds (including any diuretics, and ACE inhibitors on order. PRN acetaminophen if needed); Education regarding medications

08.45-09.15 / Breakfast – Opportunity to provide education about low sodium diet. If pain medications were provided, re-assess pain level

09.30-09.45 / Bed bath – Opportunity to provide a 20-minute foot massage

11.00-11.30 / Exercise with PT

11.30 -11.35 / Move to chair (ensure stockings are on)

12.00-12.30 / Lunch – Opportunity to provide education about low sodium diet

14.00-14.30 / Walk with patient around the ward (as much as tolerated) – Opportunity to educate on the importance of exercise

14. 30-14. 35 / Move to bed – Elevate legs with pillows, measure calves, perform pain assessment.

**Medication might be administered at more times during the day depending on the orders. Whenever pain medications are administered, pain will be re-assessed 30 minutes later.

The following criteria will be used to assess the nursing diagnosis. The patient will be able to tolerate walking the full loop of the ward by the time of discharge. The patient’s left calf will show decreased fluid retention with a calf measurement of 17” by the time of discharge. The patient will report a pain level of 2/10 by the end of the shift. The patient and/or the patient’s son will be able to articulate understanding of the education provided by the end of each shift. This will be measured by their ability to articulate the importance of taking medications on time; and the importance of compression therapy, exercise, elevation, and diet on decreasing fluid retention.

Through the implementation of this care plan, one would hope that Mrs. Sparks pain, as well as the fluid retention in her calves, would be reduced. This could have positive impacts on her ability to perform activities of daily living. The education provided would also give the patient, as well as her support system, the information they need in order to help prevent this issue from getting any worse once discharged. Additionally, this issue is a symptom of a more serious medical condition so by treating the fluid retention, you are indirectly treating the cardiac output issue at the same time, which will increase the overall health of the patient (Pellicori et al., 2015).

References

1. Alguire, P.C., & Scovell, S. (2019). Overview and management of lower extremity chronic venous disease. In J.F. Eidt, & J.S. Mills, Sr. (Ed.), Uptodate. Retrieved November 3, 2019, from https://www.uptodate.com/contents/overview-and-management-of-lower-extremity-chronic-venous-disease?csi=235adc50-2f53-44c3-8220-1d96047cfdef&source=contentShare
2. Alpert, M.A. (1990). Systolic murmurs. In H.K. Walker, & J.W. Hurst (Ed.), Clinical methods: the history, physical, and laboratory examinations. 3rd Edition (Chapter 26). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK345/
3. Bodian, C.H. (2019). 4 positive effects of exercise on the digestive system. In L. Maloney (Ed.), Livestrong. Retrieved November 3, 2019, from https://www.livestrong.com/article/356356-immediate-effects-of-exercise-in-the-digestive-system/
4. Pellicori, P., Kaur, K., & Clark, A.L. (2015). Fluid management in patients with chronic heart failure. Cardiac Failure Review, 1(2), 90-95.
5. Procter, L.D. (2018). Low blood pressure. Merck Manual Consumer Version. Retrieved November 3, 2019, from https://www.merckmanuals.com/en-ca/home/heart-and-blood-vessel-disorders/low-blood-pressure-and-shock/low-blood-pressure
6. Rausch, T., & Jansen, T. (2012). Gastrointestinal side effects of opioid analgesics. US Pharmacist, 37(12), 36-39.
7. Redman, K. (2019). Introduction to Cardiac Pharmacology [PDF Document]. Retrieved from Lecture Notes Online Website: https://canvas.ubc.ca/courses/42589/files/5688566?module_item_id=1428310
8. Simon, E.B. (2014). Leg edema assessment and management. Medsurg Nursing. 23(1), 44-53.
9. Sterns, R.H. (2019). Patient education: edema (swelling) (beyond basics). In J.P. Forman (Ed.), Uptodate. Retrieved November 3, 2019, from https://www.uptodate.com/contents/edema-swelling-beyond-the-basics/print
10. Trayes, K.P., Studdiford, J.S., Pickle, S., Tully, A.S. (2013). Edema: diagnosis and management. American Family Physician, 88(2), 102-110B.

A nursing care plan allows a nurse to identify the most pressing concerns for a client, develop nursing interventions and evaluate them. This report details a nursing care plan for a client with liver cirrhosis presenting with unresolved chronic sciatic pain. My client D.R was a gentleman who presented with this disease. He is 75 years old and quite sharp for his age. He reports that prior to his liver disease and resulting ascites over two years ago, he enjoyed good health with no complications

Assessment

D.R. is a 75-year-old male who presented to the hospital with an alpha pump infection, related to an electric pump inside his abdomen which removes ascitic fluid and directs it through the urine. Urinalysis showed E.faecalis in his urine. Previous health history included chronic liver disease and liver cirrhosis related to excessive alcohol consumption, sciatica, and tonsil removal. Upon doing the head to toe assessment (for more information on assessments, see Appendix A) client reported pain in the back that shoots down his left leg. He rated it 0 at rest and 9/10 on a 0-10 scale when he moves. I then performed the PQRSTUAA pain assessment for his pain. He informed me that he had it checked out about seven months ago and was told it was sciatic pain. He was recommended stretching and being active to relieve the pain. He informed me that the ascites limits his movement and prevents him from being as active as he was before, so it is difficult to exercise on his own. He also stated that he tried a heating pad, but it didn’t help in alleviating the pain. In terms of exercises, he told me that he tried them a few times and they reduced the pain for a couple minutes but then it returned, he stated that they were a bit difficult to do consistently. He described the pain as a “sharp zap down his leg to his foot”, he also stated that sometimes it feels worse when he sits so he lies back down to alleviate it. He said he feels it when he changes position such as when he sits up from lying down and when he starts walking.

Diagnosis

Data Analysis

From my assessments and the information I gathered from conversations with D.R. I found that relieving his pain was a priority. It was his ninth day in the hospital when I was taking care of him in my first shift of the week on Thursday. His infection was clearing with the antibiotics (see Appendix C for more information) as evidenced by blood work and clearing of his urine (it was not as cloudy, more yellowish in color, and free from the bacteria). He had no other problems besides the liver damage, nerve pain and minor skin injuries. Besides the wounds on his elbow, lower back and foot, there were red spots on his arms due to bruising from his IVs and blood tests related to his liver disease which affects clotting factors and thereby thinning his blood which pooled under his skin (Lackner & Tiniakos, 2018). Other than this, his skin was free from impairment. His heart, lung and bowel sounds were normal. He had no swelling in his legs, but according to his progress notes, he had edema in his legs and feet when he was admitted but that resolved and was not apparent when I was taking care of him. His focused neuro assessments did not display anything concerning. He was alert and oriented to person, place and time, his eyes were PERRLA and he displayed equal strength in his extremities. He had good cognitive and social functioning (see Appendix A). Potential problems included increased risk of infection due to impaired liver function and ascites, impaired skin integrity and potentially; increased risk of bleeding due to liver damage.

Problem identification

The main problems identified were his nerve pain and skin impairment (for more information see Appendix B). His infection was responding to treatment and his ascites (which was one of the main symptoms of his liver cirrhosis) was in control. His nerve pain was immobilizing him, affecting his movement, blood circulation and skin health. The skin impairment he had was mild but had the potential to become worse. Skin health is important as skin is one of the first defenses against infection. It is a physical barrier against pathogens. Due to his age (75) he is already at risk for skin impairment due to age related changes in skin elasticity and decreased turgor (Haydont, Bernard & Fontunel, 2019).

The nursing diagnosis I formulated was: Increased pain related to the sciatic nerve as evidenced by lower back pain, pain that’s worse when sitting and shooting pain down left leg while walking, fatigue, facial grimace upon change in movement, and guarding of left leg.

Planning and Implementation

Taking into consideration that his pain was limiting his movement and was affecting his ability to walk and be active, I prioritized treating his pain before the impaired skin integrity. Resolving his pain would improve his quality of life and prevent him from being bedbound. Alleviating his pain was a priority over providing wound care as it would increase his mobility and willingness to ambulate thereby decreasing his chances of incurring another pressure wound, decreasing his risk of disuse atrophy of his muscles and enable the pressure injury to heal. As when muscle is not used it shrinks in size and becomes fat. More importantly, it was a personal concern of the patient, he wanted a relief from the nerve pain that he’s been having, which seemed to become worse after he came to the hospital. He was tired of staying in bed all day.

Patient Education is a process of empowering patients to be the in charge of their own wellbeing and be more independent concerning their health management (Yeh, Wu, & Tung, 2018). It is one of the most important responsibilities of the nurses to educate the patient properly to prevent hospital readmission, improve patient’s confidence in health care and avoid relapses. Moreover, nurses’ ability to instruct efficiently can optimize patient’s learning, skills, capacities of self-care, and capabilities to make informed choices (Falvo, 2011). However, there are many key challenges of implementing patient education effectively. One of the challenges is that, the patient’s capability, capacity and willingness to learn and understand. According to Falvo (2011) “patient characteristics that may influence learning include desire to learn, prior experiences, health literacy, physiological issues, age, culture, ethnicity, language, and psychosocial factors”. London (2016) suggested “to use knowledge about patient characteristics to individualize teaching”.

In order to address this problem, nurses should begin by knowing their patient individually. They should assess the knowledge of the patient by asking what they know before and what they have to know, and to use an open-ended question to gather more information from them. “Teach-back method” is also applicable to know if the patient understands the health teaching that was being taught. Furthermore, nurses should use a language that their patients can relate to and avoid medical terms especially if their patients have no medical background. Aside from that, they should talk in a calm and clear voice. Another barrier in giving patient education is insufficient time and staff. According to Westbrook, Duffield, & Creswick (2011), “hospital nurses spend approximately 37% of their time with patients and of that time only 17% is spent in professional communication that may or may not include patient teaching”. Nurses have a limited amount of time providing patient education due to understaffing and heavy workload, they are more focused on taking care of sick patients and prioritizing the critical one. Hence, the time management is very essential in hospital settings. Nurses must include health teaching in their daily care to save time from discharge instruction. They must handover to their colleagues the teaching activities and learning needs that has given so that there is no repetition and inconsistency in health teaching.

In conclusion, patient education is very important and plays important role especially in the decision-making in regard to their care. As what Kornburger, Gibson, Sandowski, Maletta, & Klingbeil (2013) said “if patient do not understand what is being taught, the risk of complication and readmission can increase”.

Mr. Ahmad had a fall at work consequently suffered from an intracerebral hemorrhage. Mr. Ahmad was declared brain-dead on his 3rd postoperative day after undergoing craniotomy surgery. Leaving his wife and 2 teenage children. His wife was informed by his doctor and transplant coordinator of the plan to remove his kidneys, heart, liver, and corneas for transplant. When Mr. Ahmad was alive, he did not discuss with his family about organ donation and they did not opt-out of the human organ transplant act (HOTA) program. His wife questioned the doctor if he is sure that Mr. Ahmad is dead. As a Muslim, she then discussed with his elderly parents nevertheless, they had requested to continue treatment till his heart stops beating and also rejected orjugan donation. This essay will delve into the ethical principles of autonomy, beneficence, fidelity, non-maleficence, and justice. Non-maleficence and beneficence have been viewed as a primary obligation (‘Everything you need to know about organ transplants’, 2019). This essay will apply the ethical decision-making process to resolve the issue between law and ethics, and it will discuss the implications for nursing practice.

The first ethical dilemma is between beneficence and respecting the patient’s autonomy. Autonomy means to respect the individual’s right of thought, intention, and when making decisions on their healthcare treatments. Mr. Ahmad did not discuss with his family about donating his organs neither has he signed the Human Organ Transplant Act opt-out form to the removal of his body after his death. It is stated that if a person passes away in the hospital, their body parts will be donated. If Mr. Ahmad were to not donate his organs it can prolong his pain and suffering, from his relative’s point of view they want to prolong the treatment in the sense that they are unsure if Mr. Ahmad will recover, hence not wanting to donate his organs. However, being consistent with the law will help end his suffering and pain. Hence, the healthcare team should consider educating Mr. Ahmad’s wife and parents on his condition and on the benefits of donating his organs.

The medical team should uphold the ethical principle of fidelity by being faithful and loyal to our patients, and act as the patient’s advocate. As an advocate, you would want to state facts and advocate for the good of the patient. According to the Human Organ Transplant Act, Mr. Ahmad did have a choice to opt-out but he did not, and the wife has no knowledge of Mr. Ahmad wanting to transplant his organs, as a nurse we should inform the patients wife about his current situation and get an Ustad, also known as religious teacher, to inform her about the spiritual benefits, for example, it will be counted as an act of good deed where rewards occur even after passing on, it is also stated in (Majlis Ugama Islam Singapore, 2019) that it is permissible for Muslims to donate their organs for the following reasons, organ transplant and donation by the deceased is allowed in Islam because, Islam calls for the seeking of cure and treatment for illnesses, and for certain organ failure, the most effective treatment is to receive a new organ. it also states that the “Syariah” is built upon values such as care and compassion, calling for mankind to help one another and to contribute to alleviating human suffering and pain. As a nurse advocate, it is important to seek the best treatment for your patient and it can also benefit other families because other families may have difficulties having to go through financial and emotional distress while waiting for organ donors for their relatives.

The principle of justice dictates that it would be fair to the patient and family. He would pass on peacefully without any treatment and it would not prolong his suffering. As for the donee of the organ, they would get a second chance at life, and a chance to live healthily. The medical team should also be fair to both patient and family and distribute reliable resources keeping the continuation of treatment for Mr. Ahmad in the plan.

Mr. Ahmad’s Family is worried about going against their beliefs of donating his organs but, according to Majlis Ugama Islam Singapore, the fatwa committee says that it is permissible for Muslims to be included in Human Organ Transplant Act because, as mentioned in the Quran: “…and whoever saves one life, then it is as though he has saved the whole of humanity” (al-Maidah: 32) (MUIS,2007). Hence, donating his organs would be an act of Amal Jariyah (continuous charitable deed) which also supports the ethical principle of beneficence because the medical team should do good to the patient and donate his organs so more lived can be saved. Therefore, his family should not be worried about going against their religion because it is beneficial for Mr. Ahmad’s spiritual and afterlife.

We can also educate Mr. Ahmad’s wife about how organ transplant works, by explaining to her that a person who has an organ that is working very poorly, needs an organ transplant. Going through with an organ transplant can lengthen someone’s life and allow people with chronic illnesses to live a longer and more normal lifespan (Medical News Today, 2019).

Conclusion

Donating Mr. Ahmad’s organs poses many legal and ethical issues that require some serious consideration. To deal with ethical dilemmas, nurses need to be well educated on the nursing code of ethics and ethical and legal principles. They can educate the wife on possible outcomes like hospice for the patient, but the complications could be infections, depending on the outcome of the wife’s decision. In conclusion, we should donate because, Mr. Ahmad did not sign the opt-out form. In any point of his life this means it is taken as a mandated choice, meaning competent people are required to indicate yes or no. The Human Organ Transplant Act was established in 1994 he was already over the age of 21 and has the choice to but he did not opt-out, nor did he discuss with his family about donation of organs. Donating his organs can help him complete a last good deed by donating his organs and possibly saving another patient (Nursing Ethics: across the curriculum and into practice, 2019).

Taking care of patients is not same as caring for them. Healthcare system is becoming competitive day by day where patients are recognized as clients of healthcare. Nursing care involves identifying patient’s need and overcome the barriers that prevent to deliver quality care. The main issue in delivering proper care to patients is that health care system increased expenditure and turning into more profitable business. It is very necessary to create healing environment for patients to make them feel secure that they are not an object to make money.

Watson’s 10 Caritas process are the principles that connect nurses and patients through faith, trust, love, hope, caring, selflessness, spirituality, energy, and understanding. Carative factors are formation of a humanistic-altruistic systems of values, instillation of faith-hope, cultivation of sensitivity to one’s self and to others, development of a helping-trusting human caring relationship, promotion and acceptance of the expression of positive and negative feelings, systematic use of a creative problem solving and caring process, promotion of transpersonal teaching-learning, provision for supportive, protective, and/or corrective mental, physical, societal and spiritual environment, assistance with gratification of human needs and allowance for existential-phenomenological-spiritual forces (Norman, Rossillo, Skelton, 2016). The caritas process helps nurse to build therapeutic relationship to promote healing. According to Norman et al. (2016), “Our hospital has a chapel that is available at all times and are flection room in the surgical waiting area”. The Caritas processes is a guide that help a nurse establish caring behaviors into nursing practice in spiritual and loving fashion.

The act of caring arises when two human being develop and maintain helping-trusting relationship. According to Norman et al., 2016, “A key aspect in creating and sustaining a healing environment is having an executive management team that supports the stated goals and the education, time, and resources needed to implement a nursing theory”. Many new nurses are unable to connect with patients due to responsibilities, low staffing, frustration, stress which affect both patients and nurses.

Jean Watson’s theory of Human caring is a great tool to educate nurses to develop transpersonal relationship through caring patients. Today’s health care system is full of technology where care is often taken as curing patients where curing patients is much more important than spending time with patients and listen to them. It is very important for nurses to experience and practice the theory of human care which can be offer by incorporating caring theory. In order to transit this theory to nurses and other staffs, health care system should offer classes with some type of exercise where nurses are required to attain sessions to experience from patients’ point of view to help understand the concept of therapy (Norman et al., 2016). Norman et al (2016) state, “These classes included elements of self-care and ways to deepen spirituality and human connectedness”. Having these type of program helps create better healing environment because the increasingly distanced relationship between health care providers and patients where true meaning of care has lost its way which also increases the risk of medical errors.

The reason I have chosen this nursing framework is that it can help nurses to remember the steps they need to take to care for the patient they are treating. It helps nurses to identify initial problems and develop solutions to overcome these problems. I have also chosen to use NANDA, which stands for, North American Nursing Diagnosis Association. The four types of nursing diagnosis used for NANDA are:

• Problem-Focused Diagnosis: This is also known as ‘actual diagnosis.’ This is focusing on the problems present at the exact time of the nursing diagnosis.
• Risk Diagnosis: This problem does exist at the time of the actual diagnosis but is likely to develop in time.
• Health Promotion Diagnosis: This is where the nurse will motivate the patient to become involved in their care if possible and try to achieve the best possible outcome.
• Syndrome Diagnosis: This is a concern with numerous problems that are likely to present because of a certain situation. (NANDA. 2015)

An ischemic stroke occurs when a blood vessel to the brain becomes blocked, depriving the brain of much-needed oxygen and nutrient-rich blood. It usually happens when fatty material, known as atherosclerosis, builds up in the artery and causes a blockage. Blood cells are then collected here and can cause a blood clot. This causes the brain cells to die. Ischemic strokes account for 80% of all strokes in Ireland (Hickey et al. 2011). The right side of the brain controls the left side of the body. So when a right-sided stroke happens, the left side of the body is affected, such as left-sided weakness or paralysis and sensory impairment.

Dysphasia is a common side-effect of a stroke. It is the medical term used for swallowing difficulties. It can cause problems trying to swallow certain foods or liquids. Common signs are coughing or choking while eating/drinking. The presence of dysphasia can increase pulmonary complications such as aspiration pneumonia. Aspiration is the term used to describe foreign objects such as food or liquids being inhaled into the airways (De Jesus et al. 2019). Orem’s self-care deficit theory describes a self-care deficit as the impaired ability to perform the activities of daily living, such as toileting, dressing, and/or feeding (Hartweg et al. 2016)

Assessment

Upon admission of the patient, I have done a physical assessment and gathered the patient’s history at his bedside. I noticed he had weakness on his left side and was aphasic which means difficulty with talking. Aphasia is always caused by a brain injury such as a stroke (Charles et al. 2012). I asked the patient to take a small sip of water. I observed signs related to swallowing problems such as coughing, drooling, or choking. The patient began to cough after he took the first sip. To assess the patient’s left-sided weakness I asked him if he could raise or move his left-sided limbs. I also asked the patient to try unbuttoning his shirt with his right hand. The patient could not perform the tasks. I recorded his mobility as a 2 on the mobility scale, meaning the patient would need supervision or require assistance from another person (Maso et al. 2019). I assessed his emotional response to the limitation; although the patient was confused he said he understood that he may need assistance with self-care while admitted. I did a full set of vital signs to determine his baseline.

Diagnosis

After assessing the patient’s swallow I documented my diagnosis as Impaired Swallowing. Due to the patient not being able to unbutton his shirt I also made a nursing diagnosis of a Self-Care deficit. The patient’s vital signs were within normal parameters. His Glasgow Coma Scale was 14/15; this was due to initial confusion upon arrival.

Planning

My priorities here were to prevent choking and/or aspiration and to help the patient safely perform self-care activities. The patient, his sister, and I spoke about the goals we would like the patient to achieve during his admission. I informed the patient and his sister that I would be making a referral to the speech and language therapist, physiotherapist, and occupational therapist. Both the patient and his sister were happy for me to do this.

Implementation

To implement the plan of avoiding choking and/or aspiration I made sure the patient had the right amount of rest before each meal as fatigue can add to impaired swallowing. I made sure the patient was alert and awake before attempting to assist with eating. The patient was sat upright at a 90-degree angle; this position allows for easier swallowing and reduces the risk of choking and/or aspiration (Nichol et al. 2019). Oral care was performed both before and after mealtimes. Good oral care can prevent any residue from being left in the mouth afterward which can cause choking and/or aspiration. The speech and language therapist decided with the patient and me that it was best for the patient to be on a minced-moist diet. The food had to be soft, and moist and not have any hard lumps. With the patient’s liquids, the speech and language therapist thought it was best that one scoop of Nutilis Clear be added to any liquids. Nutilis Clear is a thickening powder that is added to food or liquids. The patient was happy with this. I encouraged the patient to take small amounts each time and to do it at a slow pace. I explained the importance of chewing food to avoid choking and also to intake drinks frequently throughout mealtimes to make sure no residue was left in his mouth. The patient was left in an upright position after each meal. An upright position makes sure that the food stays in the stomach until it is ready to be digested; this decreases the risk of aspiration. I made sure to observe for signs of aspiration after each meal. The sound of new crackles or wheezing could indicate food or liquid has been aspirated. I made sure to praise the patient each time as this promotes positivity and encourages the patient (Nurselabs, 2010).

When it came to assisting the patient with his self-care, I allowed the patient to do as much as he could for himself and I allowed sufficient time for this. I assisted when it was necessary. This promotes recovery and independence. Assisting when needed allows the patient to avoid frustration. I placed everything he needed on the right side of his table, such as cutlery and other essential items so that he could use his right hand to pick things up himself and use them as necessary. Encouraging the patient to do as much as possible for himself re-establishes his sense of self-worth and promotes the rehabilitation process. The rehabilitation process helps the patient to relearn skills that are lost when the brain was damaged from the stroke.

The general theme of this paper is the importance of safety. The American Association of Colleges of Nursing, otherwise known as AACN, competency chosen was quality improvement and safety. The competency chosen from Quality, Safety Education for Nursing, otherwise known as QSEN, was safety.

The reason for the selection of these competencies is based on the importance of safety within the nursing profession. Safety has become a very prominent factor within nursing. Facilities are scored and ranked on their safety scores which are made public. Many factors play into safety. QSEN states the old definition of safety was individual performance and vigilance to keep patients safe. Their new definition of safety is to minimize the risk of harm to patients and providers through system effectiveness and individual performance (QSEN Institute, 2019). Essentially, the old definition stated that it was up to the individual provider to ensure patient safety. The new definition brings together all aspects of patient care, even those indirectly linked to patient care.

We all know that a medication error is a multi-system failure when it occurs. The physician gives a verbal order or writes the order out, and the nurse picks up that order. Two nurses are supposed to ensure then this order is correct before the order is transcribed and continues in the chain of events. Once the order is submitted to the pharmacy, the pharmacist then checks for the order’s accuracy. When the pharmacist deems the order is accurate and safe, the medication is filled and sent to the floor. The nurse administering the medication then checks the order against the medication to ensure accuracy before administration. The old definition was focused on physicians, pharmacists, and nurses. The new definition is broader and focuses on the original group, but included as well are administrators writing the protocol for order entry or order transcription, pharmacy machines dispensing the medication, software used to document medication administration, and even manufacturers of said medication. All of these components work together to play a part in safety. Essentially, if all of the pieces to this complex moving machine are not cared for, well-oiled, and checked frequently for issues, there could be a system failure, which could potentially lead to patient harm.

According to Quality, Safety Education for Nursing, there are core domains. Some of these core domains are culture, leadership, risk identification and analysis, data management and system design, mitigating risk, and external factors. Culture consists of teamwork, patient involvement, education, and training. An example that would fit into this domain would be asking a patient for their home medication list and reconciling their medications with the physician for continuity of care. Risk identification and analysis consist of multiple failures. One failure is latent failure where resources or policies and procedures fail. Active failure is when the system breaks down and there is direct contact with the patient, such as a medication error. Organizational or system failure would relate to management or organizational issues. An example would be if a unit were to be understaffed below accepted or standard nurse-to-patient ratios. Technical failure would be indirect failure such as a pharmaceutical company failing to notify the facility of a drug recall.

According to QSEN, there are 1,100 medication errors daily across the United States that are reported. Weekly in the United States, 40 people have the wrong body part or extremity operated on due to provider error. Other errors related to safety include diagnostic inaccuracies, equipment failure, transfusion errors, laboratory errors, system failures such as short staffing, and environmental hazards. Patient involvement is a very important aspect of ensuring safety. When a patient is involved in reconciling their medications upon admission to the hospital, fewer medication errors might occur, or fewer adverse reactions might occur. When including a patient in a pre-surgical consult and asking them to mark the limb that is to be operated on, fewer errors are likely to occur related to the site. These are all policies, procedures, and protocols implemented because of errors and negative patient outcomes. As we continue to make errors, which do occur because we as providers are human and make mistakes, we continue to learn a better, more effective, or more efficient way of completing a task. It is extremely important to be able to speak of these errors or ‘near misses’ in order to better care for patients and minimize these errors in the future.

There have been many inventions and technological advances to assist in preventing negative patient outcomes from occurring. Some of these inventions include auto-safety syringes, needleless hub systems, and more recently bar-coded medication administration. All of these things were invented or implemented due to an issue that arose in relation to some form of patient care. Take auto-safety syringes as an example. These were invented with the thought that they would decrease the incidence of accidental needlesticks. Unfortunately, the auto safety feature of these syringes is only effective when the product is used in the exact way it was intended to be used. If it is not used according to the manufacturer’s suggestions, this tool used to prevent needlesticks is ineffective.

As we learn of issues and discover solutions that we can implement to remedy these issues, we must always remember the importance of education. We also must remember that we are nurses and we care about patients. We do not care for monitors. We must assess our patients and use the data collected from the monitors as an adjunct to our skilled assessments. Too many times a nurse has seen a patient flatline on a monitor and call the code only to get to the bedside and realize simply a lead fell off. The nurse’s role in regard to safety is one that we must consider to be on the front lines. A lot of responsibilities are placed on the nurse to be the last fail-safe before a negative patient outcome. Going back to the example previously mentioned, the nurse administering the medication is the last person to potentially notice an error and prevent that medication error from being made.

The way in which we will achieve the competency of safety is first through continuing education. It is important to always be on the forefront and know what the current issues are and the solutions available to fix those issues, whether that be new protocols, new policies, new equipment, interdisciplinary involvement, or the culture surrounding the issue. Research in the field of nursing continues to be extremely important as this discovers new ways of handling these issues and what is most effective in preventing errors from occurring. I personally continue to ask, “Is there a better way?”. Sometimes, there is a better way, and if there is, I feel it is my duty as a nurse to attempt to implement that better way. I find myself constantly searching, reading, and discussing; to try and find a more effective and safer way to deliver patient care. If we all stopped learning when we graduate from nursing school, not only would we be providing extremely basic nursing care but we would become stagnant. Education is the only constant in nursing.

Many agencies have also been created to focus on patient safety and safety in general. Some examples of these agencies are the Occupational Safety and Health Administration (OSHA), the Agency for Healthcare Research and Quality (AHRQ), the American Society for Healthcare Risk Management (ASHRM), the National Center for Patient Safety, and the National Quality Measures Clearinghouse. All of these agencies or centers have been formed to keep safety at the forefront of healthcare and maintain adequate levels of safety within healthcare facilities.

In conclusion, patient safety should be our number one priority. Without ensuring our patients’ safety, we have done a disservice to them. We need to ensure that we are at our best, emotionally, mentally, physically, and intellectually. We also must ensure every other fail-safe is in perfect, or as close to perfect, working order as possible to ensure we are guaranteeing our patients’ safety and leaving nothing to chance.

Abstract

A good proportion of young children between the ages of ten months to eleven years have been hospitalized with gastrointestinal complications. These complications more than often, result from acts of swallowing foreign objects, which are usually bits of the toys these children play with. According to the United State’s Consumer Product Safety Commission [CPSC] (2007), most of the toys children play with today, have magnet bits with them, and the number of such toys is increasing in the market. This increase has led to the rise in the number of serious injuries in children resulting from the ingestion of magnets. Ingestion of more than two magnets by children leads to serious complications like intestinal perforations since these magnets attract each other through the linings of the different loops in the intestines. These attractions often puncture intestinal wall linings. Danny, a twenty-two-month-old baby, happens to have swallowed seven small, tablet-shaped-magnets. These magnets, unfortunately, separated into two groups within his intestines, and have been attracting each other through his intestinal wall. The attraction caused two perforations of his bowel, which was repaired by surgery. Unluckily, he is back in the ward suffering several complications relating to the damage the magnets caused in his intestines. This paper demonstrates the nursing assessment of Danny, the tests undertaken by the medical staff, and the nursing management plan.

Pediatrics Case Study

The medical implication brought about by the ingestion of magnets is not a new phenomenon among young children. From the periods between 2003 and 2006, nearly twenty percent of all foreign ingestion cases reported were of magnet ingestion. Of this twenty percent, nineteen of them required gastrointestinal surgery and one of them resulted in the death of the victim (Midgett, Inkster, Rauchschwalbe, Gillice, & Gilchrist, 2006, p 1297). This paper demonstrates the nursing assessment, medical tests, and the nursing management plan given to Danny, a twenty-month-old baby who happened to have swallowed seven magnets.

Introduction

This paper is about Danny, a twenty-month-old baby who has perforations in his bowel. These perforations were caused by the act of swallowing seven small tablet-shaped magnets as the child was playing with his toys. Apart from the pain, Danny also suffers from general anesthesia.

In explaining Danny’s case, this paper is divided into four major parts, that is; a discussion of the initial complaint, which talks about the ingestion of the magnet and the bowel perforations together with the surgical repairs. The next section discusses the assessment of Danny by the nurse and the medical tests that the staff will undertake. The third section outlines the Management plan and the fourth part evaluates the effectiveness of the care given to Danny and his family during the whole process. This paper has been written from the time Danny arrived in the emergency department, up to the point he started improving from his condition. The assessment starts from the time the child arrived in the emergency department and the care plan only appertains to the ward.

Discussion of Initial Complaint

Danny was brought to the emergency department of the hospital by his mother and was immediately admitted due to the seriousness of his condition. He was admitted with sharp abdominal pain, severe in the upper abdomen. Danny had been in excellent health and only after waking up several times complaining of stomach pains did his mother get concerned. In addition to the pains, he had several episodes of vomiting and signs of dehydration indicated by red notches and bluish tinges to his hands and feet. He also experienced high fever, chills, and nausea.

On scrutiny and inquiry from the mother, she confesses that Danny had swallowed some button-like pieces of magnets which fell off from his toys. An x-ray of the upper abdomen showed the existence of foreign immobile objects obstructing the mouth of his large intestines. These foreign objects were found to be seven small tablet-shaped magnets. The laparoscopy carried out found out that these magnets were stuck together pinching the bowel tissues. The act of pinching the bowel tissues had resulted in bowel perforation and it is what caused the sharp abdominal pains.

Ingestion of magnets and bowel perforations are life-threatening conditions normally categorized as medical emergencies that need surgical repair and peritoneal lavage. These complications if not corrected early can lead to unexpected deaths. Other foreign bodies when swallowed by a person will be automatically expelled from the body through the normal body functions. Ingested magnets on the hand are not so and specifically where they have separated into two groups and started attracting one another. They become difficult to remove from the intestines (Walker, 2008, p. 2). As they continue attracting one another, they ultimately cause problems by preventing blood flow in the intestines, resulting in perforations in the bowels. The majority of parents and pediatricians assume that ingested magnets will be passed on, which is never the case.

Magnets in the bowels lead to further serious complications like volvulus, sepsis, ulceration, bowel resection, peritonitis, and bowel necrosis (Weintrub, 2007, 45). These complications can only result if the magnets are not removed early as possible. The perforations can only be corrected by surgery, which is done to repair the holes either through the removal of a small part of the intestine or by joining the torn tissues. This removal can also be done through temporary ileostomy or colostomy. Alternatively, the surgical removal can be through exploratory laparotomy or closing the perforations through medical evacuation (Hockenberry, Wilson, Rentfro, & McCampbell, 2006, p 23).

The complications that accompany perforation treatment include bleeding, contraction of infections like sepsis, which can lead to the death of the victim, and intra-abdominal abscess. Early treatment of ingestion of magnets and bowel proliferation is of prime importance since it helps prevent further complications, which could lead to the death of the victims.

Discussion of Assessment

Danny was brought to the emergency department by his mother who was extremely concerned about his high fever, abdominal pains, and concurrent vomiting. Danny will be picked up from the recovery by a nurse accompanied by his mother. This accompaniment is necessary because Danny is a toddler and most of the things he is going through it his mother who can explain them better. It is also a good ethical medical practice for one of the parents to be available during the tests, and in this case, it is the mother who is accessible. The presence of the mother will also help to reduce stress in case the child is distressed in the room. Another reason for this accompaniment is that some tests require the consent of an elderly adult specifically a parent or a relative.

On return to the ward, the nurse will run several tests and assessments on Danny like maintaining airway breathing circulation. The tests that will be carried out on Danny include radiology tests, specifically an x-ray of his abdomen. Apart from the x-ray test, the nurse will run a stool test to ascertain what is wrong with the child’s gastrointestinal system. Still in the ward, the nurse will check his temperature readings, pulse rate, respiration rate, and SpO2 (Rosdahl & Kowalski, 2008, p. 1246). Tests will also be done on him to ascertain the level of pain he is experiencing.

Nursing Care Plan

Identification and description of the patient

The patient is known as Danny: he is twenty months old and has a four-year-old sister by the name of Charlotte. He is mostly under the care of his mother who looks after them since his father works offshore on an oil rig, and is mostly away from the family. The child had ingested a total of seven-minute tablet-fashioned pieces of magnets which might have dropped from his playing toys. These seven magnets separated and formed two groups that kept on attracting one another in his bowels. This later caused perforations in his bowels which were corrected by surgery. The correction left him with a central abdominal wound which has subcutaneous sutures. This wound is always covered with a clear dressing and experiences minimal leakages. The assessment gave the following readings of Danny’s situation; his temperature was 37.4oc, his pulse rate was one hundred and six, his respiration rate was twenty-four and his SpO2 was ninety-eight percent in room air.

Family Situation

Danny is mostly under the care of his mother since his father works away. An assessment of this situation suggests that the mother needs help in bringing up the two kids more so when one of them is unwell. Teamwork between the two parents is necessary to help Danny recover faster and also to help Charlotte the older sister in the same. Family-centered care is highly advised for Danny being a child in his early year of life. He needs constant attention, and care from both his parents. This management plan involves training the parents on how to handle him effectively and ensure he recovers faster.

Medication

Danny has been experiencing abdominal pain regularly portrayed through his acts of squirming, moans, and occasional whimpers. He has a continuous morphine infusion to relieve him from the intense pain. Morphine is a narcotic pain reliever used to treat moderate to severe forms of pain (Twycross, Dowden, & Bruce, 2009, p. 16). This drug operates by dulling the pain perception area of the brain and is used in short-acting and extended-release formulations to deal with pain. The side effects of this drug include experiences of shallow breathing and a slow heartbeat, seizure attacks, cold and clammy skin, and confusion (Browne, Flanigan, McComiskey, & Pieper, 2004, p. 578). The contraindications of the use of this drug include hypersensitivity to morphine sulfate. This hypersensitivity or allergy makes it dangerous to use when the patient is in a convulsive state since it has a stimulating effect on the spinal cord. This drug is also contraindicated in respiratory depression, heart failure, bronchial asthma, cardiac arrhythmias, brain tumor, and delirium tremens among others (Cote, 2001, p. 56).

Other antibiotics which could be effective in reducing pain in Danny’s case include Acetaminophen, which is also known as Tylenol, a nonaspirin pain reliever easier on children’s stomachs (Beevi, 2009, p. 51). This medication is safer for children and is strongly recommended by doctors since it has fewer side effects and contraindication which are feelings of nausea and vomiting in case of an allergy. Due to the risk of the wound being contaminated, the dressing should be replaced daily and the wound washed with antiseptic. His breathing should also be monitored frequently until it comes back to normal. This drug forms the dose that Danny will be on again until his pain ceases and the abdominal wound heals completely. Danny will be on continual use of antibiotics since his immune system is not that well developed to fight the disease-causing pathogens that can enter his abdominal wounds. The use of antibiotics boosts his immune systems and helps to fight the germs and this facilitates the healing process. In dealing with general anesthesia, a preoperative assessment is recommended before he is taken to the anesthetic room.

Evaluation

The care that has been prescribed for Danny and his family is in line with the current best practice as required of any nursing plan program. The evaluation is also in line with the requirements of the American board of pediatrics.

Summary and Conclusion

This paper describes the nursing care plan for Danny who suffers from perforated bowels caused by swallowing seven magnets. This plan has explained in detail the causes, and consequences of this condition if left untreated. It also outlines the drugs that can be used to relieve, since this complication can only be corrected through surgery as it was done in the child’s case. Further to this, it also emphasizes family-centered care for this twenty-month-old child, since it is what is best for him. In addition, it provides a management plan to deal with his general anesthesia. Lastly, it evaluates the program by the generally acceptable nursing practices and finds it fit and applicable.

References

Beevi, A. (2009). Textbook of pediatric nursing. Noida: Elsevier.

Browne, N. T., Flanigan, L. M., McComiskey, C. A., & Pieper, P. (2007). Nursing care of the pediatric surgical patient (2nd ed.). Sudbury, MA: Jones and Bartlett.

Consumer Product Safety Commision. (2007). Small magnets are injuring children; CPSC releases stronger warning to parents. Web.

Cote, C. J. (2001). A practice of anesthesia for infants and children. Ann Arbor, MI. Saunders.

Hockenberry, M. J., Wilson, D., Rentfro, A. R., & McCampbell, L. W. (2006). Wong’s nursing care of infants and children (8th ed.). Philadelphia, PA: Elsevier Science Health Science div.

Midgett, J., Inkster, S., Rauchschwalbe, R., Gillice, M., & Gilchrist, J. (2006). Gastrointestinal injuries from magnetic ingestion in children – United States, 2003-2006. Morbidity & Mortality Weekly Report, 55(48), 1296-1300.

Rosdahl, C. B., & Kowalski, M. T. (2008). Textbook of basic nursing (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Twycross, A., Dowden, S., & Bruce, E. (2009). Managing pain in children: A clinical guide. Oxford: Blackwell.

Walker, W. A. (2008). Walker’s pediatric gastrointestinal disease: Physiology, diagnosis, management, volume 2. Hamilton, ON: PMPH-USA.

Weintrub, P. S. (2007). Ingestion of magnets: Trouble when opposite attract. Journal Watch Pediatrics and Adolescent Medicine. Web.

The aged population forms a majority of the proportion that needs special healthcare, this due to the fact that they require unique and diverse needs that comes only with old age. Boult et al. (1994) affirm that most of the aged suffer from chronic conditions and illnesses that require special and personal attention due to the psychological changes they undergo as they age (p. 28). This paper provides an assessment of SM; an elderly patient, and provides a care plan that identifies two of her nursing diagnosis needs.

Identification and Description of the Client

The client is known as SM; she is seventy two years old and was born on the twenty-eighth of February 1940. SM is a divorced female and a mother of two daughters and two sons, eight grandchildren, and three great grandchildren. SM worked for forty years as a sterilization technician and supervisor in the operating room at Our Lady of Bellefonte Hospital before retiring.

The Clients Strengths

• She is active around the house and does her own laundry, cooks her own meals, and does much of her own housework.
• She is able to complete bathing, dressing, transferring, feeding, and continence on her own without any assistance.
• She is able to use the telephone, do shopping, use transportation, and take responsibility for her own medication without any assistance.
• She does not have any cognitive impairment, and she is mentally alert and oriented
• She is able to drive the car, manage her own financial resources like writing checks without any assistance.

The Client’s Weaknesses

• She is poor in health and has a medical history of heart disease, diabetes, hypertension, and hypothyroidism.
• She has difficulty with seeing in distances which makes her use spectacles in both distance and in reading.
• She has hearing problems and is HOH in both ears but marked worse in the right ear.
• She has dental problems and most of her teeth are decayed needing extraction.
• She is diabetic but continues to eat sweets for breakfast and does not monitor her diet as a whole; this has resulted into her being obese.
• She is ignorant on diet issues, since she believes that her thoughts and choices concerning what she eats will not make a difference in her blood sugar because the problem is genetic.
• She is at risk of falls because she is somewhat unsteady when turning around.
• She has poor strength and stamina due to her inability to stand from a seated position suggesting she needs simple exercises or physical assessment.
• She has difficulty with the serial number seven.

Overall impression of Client’s Needs

SM has a number of chronic complications which require special attention. First of all, she has a medical history of heart disease, hypertension, hypothyroidism, and diabetes. In addition she is obese, has a pink, warm, and dry skin, and has evidence of varicose veins. SM also has dental problems with most of her teeth decayed requiring extraction.

These conditions place her in a position of need requiring special attention from both family members and from the medical field. First of all, SM needs education on the importance of watching her diet and weight so that she can regulate what she eats and gets involved in regular exercise. Dieting will help reduce her weight and eliminate unwanted sugars from her body and the exercises will keep her fit, alert and improve her stamina. She also needs to be educated on the importance of hearing aids to help boost her hearing abilities. In addition she needs financial support to pay the oral surgeons bill to have her decayed teeth extracted. Above all SM needs education concerning her thoughts on her health life, since her presumptions are not necessarily true.

Summary and Interpretation of Assessment

From the assessment of the client, her lungs were clear to auscultation, her temperature was ninety-eight point three, her blood pressure was 128/84 and her pulse rate was seventy. SM’s nutritional screen was 6+; she weighs two hundred and thirty five pounds, and is five feet six inches tall. Her functional performance test scored four, her gait speed was greater than five point six seconds, and her pace was slower totaling to nine point four seconds. SM’s Katz score was six, her mini mental status scored twenty five and her brief pain inventory results revealed that she was not in any pain at the time of the assessment. The client’s instrumental activities of daily living scale shows that she can carry out a number of activities like preparing her own meals, doing household chores among other minor activities without any assistance.

The assessment also reveals that the client is on medication, and he medication list includes; Coumadin which she takes as a blood thinner once every day and Lasix which she takes as a fluid pill twice every day. She also takes Clonidine for her blood pressure, Pravastatin for her cholesterol levels, Metoprolol for blood pressure and Gyburide which she takes as a sugar pill. In addition to these, she also takes Synthroid for her thyroid, Diovan for her blood pressure, and Aspirin which she is not sure why she takes as her doctor told her to take it.

Nursing Care Plan for SM

This nursing care plan simply outlines the nursing care to be provided to the client. It includes a set of actions that the caring nurse will implement to support or resolve the nursing diagnoses that have been identified by the nursing assessment. The North American Nursing Diagnosis Association (2011) requires that the nursing plan contain a nursing diagnosis which provides the criteria for selecting the best nursing intervention. In this respect this paper develops two care plans for two of SM’s diagnostic needs that are, high blood pressure and diabetes.

High Blood Pressure or Hypertension Care Plan

Diabetes Care Plan

In conclusion SM requires immediate medical attention, and if the plan described above is well adhered to, her progress monitored daily, progress will be observed.

References

Boult, C., Kane, R. L., Louis, T. A., Boult, L., & McCaffrey, D. (1994). Chronic conditions that lead to functional limitation in the elderly. Journal of Gerontology, 49(1), 28- 36.

Earl, S. F., Giles, W. H., Dietz, W. H. Robert, G. H., & Houza, T. M. (2002). Prevalence of the metabolic syndrome among US adults. JAMA, 287(3), 356-359.

Mitty, E., & Mezey, M. (1999). Integrating advanced practice nurses in home care: Recommendations for a teaching home care program. Nursing and Healthcare Perspectives, 19 (6), 264-270.

North American Nursing Diagnosis Association. (2011). Diagnosis development. Web.

A crucial part of the nursing care plan, a change in the lifestyle of most of the family members must be made so that further improvements could be observed. One of the most important issues to focus on, the so-called “pitting,” or cutaneous, edema that Mother B has, must be tended to in a proper manner. It is necessary that the edema should not progress until it turns into generalized. In other words, it is crucial that the key reasons for the disease development should be defined. Apart from the nutrition issues, which will be analyzed below, a range of changes of the Mother B’s lifestyle must be made. First and most obvious, it will be highly recommended that the sedentary lifestyle should be substituted with a more active one. In other words, it is recommended that Mother B should take regular daily walks (Atkin, 2013).

Seeing how the aforementioned pitting edema is usually accompanied by varicose veins, it will be necessary to carry out a therapy, which will provide either treatment of the condition, in case Mother B has the aforementioned disease, or an efficient prevention of the problem, if Mother B has not developed the given problem yet. To address the problem of varicose veins, it will be required to use compression stockings. Naturally, surgery seems to be the best choice possible in the given situation, seeing how it will help get rid of the problem for a considerable time; however, taking Mother B’s age into account, one must admit that the procedure may have a very negative effect on her heart and, therefore, cause even more health concerns. Mr. B, who is diagnosed with diabetes, should adopt a less sedentary lifestyle as well (Biddle, Davies, Khunti, & Yates, 2012).

Suggested dietary modifications

As the official data states, the key to the problems of the family that has been monitored concerns rather poor nutrition; particularly, extremely high rates of fats and sucrose. It is essential to keep in mind that some of the diseases have been considered as hereditary; for instance, the fact that one of the family members has diabetes can be explained by the hereditary predisposition of the patient. Herein lies the key to defining the nutrition features for not only the specified family member, but also for the Mother B and Mrs. B. Indeed, seeing how the son has developed diabetes, it is suggested that the mother is under a considerable threat of developing the specified disease in the future as well. Hence, it is required that the nutrition strategy adopted in the family should be shifted towards reducing the number of fats assumed on a daily basis, as well as the consumption of sucrose. However, low sugar levels in blood may also trigger drastic consequences in Mr. B’s health; therefore, it is important that Mr. B.’s daily intake of food should not be lower than the one of his medicine. Otherwise, a rapid drop of blood sugar and the following health problems will ensue. Finally, in the light of the fact that Philippino people, whom the mother of the family belongs to are predisposed to increased rates of sodium, it will be necessary to restrict the daily intake of salt and the products that contain it (Amadora-Nolasco, 2008; Tejero & Fowler, 2012).

Finally, the fact that Mother B’s pitting edema has most likely been caused by increased consumption of water suggests that the aforementioned element of her daily meals intake should be reduced to 1.5 – 2 liters. While cutting down the consumption of liquid and specifically water is quite dangerous and may lead to body dehydration, the overconsumption of liquid, in its turn, will trigger a rapid progress of the disease. The results may be drastic; therefore, the amount o water consumed on a daily basis must be must be cut to the minimum (1.5–2 liters). Instead, the food that contains large amounts of fluid, e.g., soups, juice, fruits, etc. must be included into the menu.

Summarizing the diet mentioned above, it will be reasonable to suggest that the family should follow the principles of a balanced diet and reduce the amounts of sugar, fats and water consumed (Biddle, Davies, Khunti, & Yates, 2012).

Medical screening needs

For the family in question to maintain stable high health status, it will be required to conduct regular medical screening. Though the introduction of a balanced diet is clearly the first and the most important step towards improving the current situation, regular checks will also need to be carried out in order to spot the possible instances of recidivism and prevent them at the earliest stage of their development (Atkin, 2013).

Complementary therapies and education tools

Apart from making the aforementioned change and taking regular health checks, the members of the family under discussion will need to undergo several complementary therapies. First and most obvious, the pitting edema, which has developed in the Mother B’s ankles and legs, needs to be addressed. In addition, as far as Mr. B’s diabetes is concerned, it will be necessary to visit doctor for regular blood sugar rate checks. For the family to be aware of the health issues that they have to deal with and the threats that they face, regular consultations with the general practitioner will be required (Biddle, Davies, Khunti, & Yates, 2012).

Reference List

Amadora-Nolasco, F. (2008). Women’s health challenges in a low-income Philippine urban neighborhood. Journal of International Women’s Studies, 10(2), 92.

Atkin, S. (2013). Bilateral pitting oedema with multiple aetiologies. Australian Journal of Herbal Medicine, 25(2), 79–82.

Biddle, S. J. H., Davies, M., Khunti, K., & Yates, T. (2012). Standing up to diabetes: sedentary behavior matters. Encyclopedia of Women in Today’s World, 1, 385–387.

Tejero, K. & Fowler, C. (2012). Migration of women from the Philippines: implications for healthcare delivery. International Journal of Social Economics, 23(8), 46–75.