Implement and monitor nursing for older clients
CASE STUDY AND CARE PLAN
CASE STUDY
Mrs Jones is 85 years old and lives in a nursing home. She has been unable to walk since suffering a CVA 2 year ago. She requires full assistance to transfer and change position in bed. She has a history of Type II Diabetes which is controlled by diet. She has COAD and Osteoarthritis. She has a hearing loss in her left ear and uses a hearing aid. Her weight is within normal range but she has had a recent weight loss of 4 kg. While her appetite was previously good, over the past month she has required a lot of assistance and encouragement with food and fluids. Deterioration in her general condition has been noted and she is reportedly increasingly drowsy and reluctant to be positioned regularly. She is incontinent of faeces and urine which is managed with incontinence pads. She normally sits out of bed for 4-6 hours per day in a recliner chair but otherwise spend the remainder of the day in bed.
ASSESSMENT
On routine skin inspection Mrs Jones was assessed to have a superficial abrasion measuring 3-4 cm over her sacrum. The wound bed was covered in a thin layer of yellow slough and there was a moderate amount of yellow stained, slightly malodorous exudate. On palpation the surrounding skin is noted to be indurated and dark red. The edges of the wound are level with the surrounding skin, which is macerated due to contact with wound exudate and urine. Although she cannot articulate her pain level Mrs Jones appears restless when the wound is touched or she is repositioned.
Research and fully discuss any disease processes, outlining the causes, symptoms, observations and how preferred treatments can affect nursing care. Also describe the history and progression of the disease. Using the Nursing Care Plan Template write your own care plan for Mrs Jones addressing each problem. You should have at least 2 (two) Nursing diagnoses per condition identified.
Based on the current status of Mrs Jones, prognosis it is important to include for each Nursing Diagnosis, assessment, goals, interventions, rationale and evaluation. It is important that you support your recommendations with authoritative sources and cited appropriately as per Harvard style guidelines.
Nursing assessment/ Diagnosis:
Goals/ Desired outcomes:
Indicators:
Timeframe:
Interventions
Rationale
Activities
Evaluation
