Assessment and Nursing Care Plans
Clustered Case Study
Mr. Smith is an 83 year old gentleman (DOB 1.2.1928), who lives alone in his home on a cattle farm west of Ravenshoe. At 0800hrs today he suffered a fall, which he says was caused by uneven flooring. Ambulance was notified by the company who supplied his emergency bracelet which he managed to activate. He was taken to the closest hospital for treatment. On examination by the doctors at the hospital, it was decided that he needed to be transferred to Cairns Base Hospital for x-rays and a CT scan in order to rule out a fractured hip.
An x-ray at the Cairns Base Hospital revealed a fractured Left neck of femur - he requires admission and surgery to repair the fracture. Patients who require a hip replacement usually require at least a 3 week hospital stay. Mr. Smith has been admitted to the ward you are working on. You have been allocated Mr. Smith as your patient. He is very upset about leaving his home town and is also complaining of pain. The following information was collected during his admission assessment.
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Name: Mr. Roberto Smith
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BP: 178/110
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He forgot to bring his medication, but knows he takes a sedative and a diuretic
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DOB: 1.2.1928
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R: 22
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He is very upset that he cannot go home
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Religion: Catholic
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P:52
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He is worried about his cows and his pet cat
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Smokes 30 a day
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T: 37.7
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His general appearance is - unkempt
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Drinks 4 beers a day
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SaO2 95% RA
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He says he has not been feeling very well lately so has been unable to shave
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Lives alone
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Wt: 120 kg
BSL 2.0 mmol/L
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He states that he is having trouble getting in and out of the shower
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Widow of 2 years
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Ht: 170 cm
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He is on a pension
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Wears glasses to see due to deteriorated eyesight
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Past medical history of arthritis, hypertension and diabetes
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Meals on wheels deliver some meals once a week - he doesn't really know how to cook - that was his wife's job
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Family lives 40 minutes away from his home, daughter does weekly shop for him
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States he hasn't been sleeping well at night lately as he is feeling lonely and anxious
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Mr. Smith has resided in Australia for the past 50 years since emigrating from Italy after the 2nd World War.
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Mr. Smith has 100 Cows on his farm
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Mr. Smith's daughter is the local Mayor
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He is able to speak English however says that he has never learnt to read or write
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He says he doesn't have many friends as he can't drive any more
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His home is a 2 storey building with stairs
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He has a large oozing laceration on his right foot which he states he did on a fence last week
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Case Study
Q1 Explain THREE (3) examples of how would you orientate Mr Smith and his daughter to the ward to ensure a safe environment including the development of a therapeutic relationship?
Q2 Explain TWO (2) examples of cultural factors which may impact on your care for Mr Smith
Q3 Complete the FALL assessment form with the information provided for Mr. Smith as per organisation policy and procedures. (Copy of form on My.Tafe)
Q4 Looking at what you know from the case study, identify THREE (3) other areas of information- Not already included in the case study scenario,you need to collect from Mr Smith in order to complete his admission history?
Q5 Record Mr. Smith's vital signs on the General Observation Sheet as per organisation policy and procedures (Copy on My.Tafe)
Q6 From the information in the case study
A) Explain which of Mr Smith's observations are within normal limits and which are abnormal?
B) Identify and explain your choice of TWO (2) other additional observations which would be appropriate to Mr Smith's care? Not already included in the case study scenario
C) From the Case Study - Mr Smith is complaining of pain. Describe at least FOUR(4) questions you could ask to assess Mr Smith's pain
D) Explain TWO (2) strategies for reporting this information to the health care team
Q7 From an analysis of Mr Smith's case study, there are areas of concern/ risk that need to be brought to the attention of the Registered Nurse for inclusion in Mr Smith's Care Plan.
A) Explain why the following examples are actual nursing care needs for Mr Smith and need to be included in his care plan
I. Wound Management
II.Hypertension
III.Identify and explain ONE further actual nursing care need for Mr Smith
B) Describe TWO (2) strategies per example for managing these actual needs
C) Explain why Mr Smith is at risk of the following potential nursing care needs,
- Pressure area breakdown
- Falls Risk
- Identify ONE further potential nursing care need for Mr Smith
D) Describe TWO (2) risk prevention strategies appropriate to Mr Smith's care needs for each example in part C)
Q8 From the information you have available explain why Mr Smith may need assistance with each of the following activities of daily living
1. Hygiene, including Showering/grooming/shaving/
2. Oral hygiene
3. Feeding
4. Toileting
5. Mobilising
6. Comfort/ Sleeping/ Rest
Q9. Describe at least TWO (2) ways you would assess and evaluate Mr Smith's care needs including his ability to perform the activities of daily living identified in Q8
Q10. Identify and explain why you may need to consult with THREE (3) other none nursing members of the multidisciplinary team in regard to the ongoing assessment and evaluation of Mr Smith's care?
Q11 A) When would the discharge planning for Mr Smith start?
B) Describe at least 3 persons who would need to be involved in discharge planning?
Q12 A) Identify TWO (2) support agencies and the services offered, which may be needed by Mr Smith when he is discharged home
B) Describe TWO (2) examples of how this care is organized including documentation required, prior to Mr Smith going home.