You have commenced your clinical placement at Curtin Hospital on Ward 9A Medical Ward. Following handover you have been allocated Heather Cook, aged 48 years, diagnosed with Multiple Sclerosis. Heather was admitted earlier this afternoon to Ward 9A for management of her Stage 1 pressure injury.
You have been asked by your buddy nurse to write Heather’s care plan from admission to discharge. Your buddy nurse completed the nursing assessment following Gordon’s Health Assessment Framework which is provided below.
Using the Gordon’s Health Assessment Framework provided please complete a care plan for
Heather. Your care plan must include the following:
Four of the most important nursing problems need to be identified and written appropriately as nursing diagnostic statements.
You will need to write one expected outcome for each nursing diagnostic statement identified.
Four nursing interventions for each nursing diagnostic statement need to be identified.
One scientific rationale needs to be provided for each nursing intervention. Each rationale will relate to, support and provide validity for the intervention. Each rationale is to be referenced.
You will need to include one handover of care using iSoBAR for the next shift.
You will need to include one discharge plan for all identified nursing problems.
Acute pain related to stage one pressure injury
Acute pain (Herdman and kamitsuru,2014) related to stage one pressure injury on her right ischial tuberosity as evidenced by pain score 7 out of 10, by on questioning Heather stated that she has pain and she described the pain as “it really hurts if I sit for too long in my wheelchair due to the community nurse who helped her in bathing, shifting and doing other routine activities. When she has to wait too long on wheelchair for her home nurse to come then it causes her great pain because she even cannot shift to bed for her afternoon sleep without their support.
The patient shall verbalize relief of pain to a scale of 4/10 by the end of four hours
Relieving pressure on the injury area by use of a special pillow, foam cushions or mattress pads. Water or air filled pads may also be used. Patient position every 15 minutes will also be practiced
Relieving pressure will increase blood flow to the pressure area and hence pain relief (Joyner and Casey, 2015).
Wash the pressure area gently with mild soap and water and dry after washing. The area should never be massaged. Moisture barrier can also be used to prevent fluid on the area.
This will help enhance comfort and also encourage blood flow around the pressure area hence relieving pain around the area (Mclnnes, et.al, 2015).
Administer analgesics such as non-steroidal anti-inflammatory drugs (NSAIDS) as prescribed. Paracetamol 1g is helpful in mild pain and opioids can be used for severe pain. Heather cook will need non opioids such as morphine since her pain is severe (7/10) (Dowell, Haegerich, & Chou, 2016). Side effects of this drugs should be monitored closely.
Opioids relief pain by binding to receptors found in brain, spinal cord and other nervous tissue which are normally activated by enkephalins and endorphin (Nalini, Howar, & Laxmaiah, 2011). Binding to receptors of the pressure area leads to pain relief.
Explain to the client the causes of pain or discomfort and the importance of care of the pressure area especially during discharge to home. Highlight the importance of taking prescribed medication as prescribe and at the right time.
Patient’s knowledge on precipitating factors of pain is helpful as it helps to control pain (Linton, & Shaw, 2011). Therefore, the patient will avoid unnecessary pain. This creates cooperation in pain management (Latimer, Chaboyer, & Gillespie, 2014).
Risk of infection related to indwelling catheter (Newman, & Willson, 2011), hospitalization and lowered immunity due to multiple sclerosis
Risk of infection related to indwelling catheter
Heather to remain free from infection and be able to pick out any signs of infections early to allow for immediate treatment
Monitor Heather for any signs of pain, swelling, redness or purulent discharge around the catheter areas or wounds. Educate the patient concerning this sign and to inform the nurse in case she notices any.
Pain, swelling, redness, discharge are the classic signs which indicate presence of infection (Surrena, 2010). therefore, noticing such signs will be a clear indication of infection. educating the Patient concerning the signs will also encourage early detection.
Assess the skin often for moisture, elasticity, color and texture (Dillon, 2015).
Skin is the body’s first line of defense against pathogens, therefore assessing it carefully and in a proper way will help in preventing its breakdown. In case of impaired skin integrity, pathogens will easily enter into the body through the breaks and hence causing infections.
Ensure that sterile technique is strictly observed when the urinary catheter is being changed and that the catheters are appropriately cared for in every shift.
Nosocomial infections commonly occur through the genito-urinary tract (Jordan, & Nicolle, 2014).
Practice proper hand washing mechanism before and after being in contact with the patient and her environment and also teach her how to wash hands properly and why she should do so. Visitors and other health staff should also be encouraged to wash their hands before handling the patient
Proper hand washing effectively remove microorganism from the hands (Lynn, 2018). This therefore greatly lowers the spreading of pathogens form one individual to a patient and also form one part of the body to another.
Bowel incontinence related to multiple sclerosis (Halper, Harris, & MSCN, 2016) as evidenced by the patient having an indwelling catheter to remove waste.
The patient to be able to be continent of stool and bowel incontinence episodes to be decreased.
Assess Heathers normal pattern for bowel elimination.
Normal bowel incontinence differs from patient to patient (Blekken, Vinsnes, Gjeilo, & Bliss, 2018). Heather’s bowel opens second daily. Check to ensure that this pattern is monitored
Fluid intake to be at least 3000ml per day unless it is indicated otherwise.
Hard dry stool does not move easily through the bowel but moist stool move easily and helps prevents impaction (Hill, 2015).
Encourage high-fiber diet, but with instructions from a nutritionist, unless contraindicated
Fiber absorbs fluid and is insoluble, therefore it helps in bowel elimination as the stool passes through the bowel (Jones 2015).
Bowel incontinence related to multiple sclerosis
Educate the client on what causes the bowel incontinence that is related to his condition and the importance of fluid and fiber in enhancing soft stool.
Teaching the patient will relieve anxiety and also helps the client to understand his condition which will make him cooperate during his care(Latimer, Chaboyer, & Gillespie, 2014).
Identity: Hi, my name is -. I am a student from Curtin hospital ward 9A a medical ward. I am handing over about my patient known by the name of Heather Cook, 48 years old woman.
Situation: My patient was admitted from home with her husband in attendance. She had a non-blanchable redness over her right ischial tuberosity on examination. The skin was intact and had a long term IDC insitu.
Observation: Recent vital signs include respiratory rate of 24 breaths per minute, pulse of 138 bpm, blood pressure of 100/80 mmHg and temperature of 37.7 on admission. The patient complained of pain. The score out of 7 out of 10.
Background: Heather was diagnosed with multiple sclerosis when she was 30 years old. She has been managing her condition well with the help of nurses at her home. The pressure ulcer was a result of her sitting on her wheel chair for a long time because the nurses were coming late. The patient is not on any current medication and no known drug reaction.
Agreed plan: Continue with management of the stage one pressure area to prevent it from advancing more.
Recommendation: Continue monitoring vital signs and relief pressure every 15 minutes by changing patient position. Pain monitoring should also be done.
Heather was admitted to ward 9A for management of stage 1 pressure injury. She is married, Anglo-Australian, Anglican lady and she came accompanied by her husband.
Advise the guardian or husband to ensure that medications are given at home as prescribed without fail in order to ensure maximum management of symptoms. Encourage them to consult whenever they encounter a challenge concerning medications and to avoid over the counter drugs. Advise them to also provide an environment that is clean while at home and also a safe environment since heather does not move easily.
Heather to be instructed to continue taking fluids of up to 3000 ml per day and ensure that he have a complete bed rest. Teach to maintain hygiene by ensuring that he bath daily and to also continue with proper hand washing technique. Encourage Heather to continue with follow-up by the doctor. Teach also on how to eat proper balanced diet while at home and on the importance of taking food rich in fiber concerning her condition. The family to also be provided with emotional support and be reassured concerning Heather’s condition.
Handover of care using iSoBAR
Blekken, L. E., Vinsnes, A. G., Gjeilo, K. H., & Bliss, D. Z. (2018). Management of Fecal Incontinence in Older Adults in Long-Term Care. In Management of Fecal Incontinence for the Advanced Practice Nurse (pp. 149-169). Springer, Cham.
Dillon, P. M. (2015). Nursing Health Assessment The Foundation of Clinical Practice: Nursing's Role in Health-Care Delivery. FA Davis.
Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. Jama, 315(15), 1624-1645.
Halper, J., Harris, C., & MSCN, N. (2016). Nursing practice in multiple sclerosis: a core curriculum. Springer Publishing Company.
Herdman, H. T., & Kamitsuru, S. (Eds.). (2017). Nursing Diagnoses: Definitions & Classification 2018-2020. Thieme.
Hill, M. (2015). Intestinal Health: A Practical Guide to Complete Abdominal Comfort. Rowman & Littlefield.
Jones, M. L. (2015). Management of elimination, 5-3: diarrhoea and constipation. British Journal of Healthcare Assistants, 9(7), 327-329.
Jordan, R. P., & Nicolle, L. E. (2014). Preventing Infection Associated with Urethral Catheter Biofilms. In Biofilms in Infection Prevention and Control (pp. 287-309).
Joyner, M. J., & Casey, D. P. (2015). Regulation of increased blood flow (hyperemia) to muscles during exercise: a hierarchy of competing physiological needs. Physiological reviews, 95(2), 549-601.
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Lynn, P. (2018). Taylor's clinical nursing skills: a nursing process approach. Lippincott Williams & Wilkins.
Meads, C., Glover, M., Dimmock, P., & Pokhrel, S. (2016). Parafricta bootees and undergarments to reduce skin breakdown in people with or at risk of pressure ulcers: a NICE medical technologies guidance. Applied health economics and health policy, 14(6), 635-646.
McInnes, E., Jammali?Blasi, A., Bell?Syer, S. E., Dumville, J. C., Middleton, V., & Cullum, N. (2015). Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews, (9).
Nalini Sehgal, M., Howard Smith, M., & Laxmaiah Manchikanti, M. (2011). Peripherally acting opioids and clinical implications for pain control. Pain Physician, 14, 249-258.
Newman, D. K., & Willson, M. M. (2011). Review of intermittent catheterization and current best practices. Urologic nursing, 31(1).
Panicker, J. N., Fowler, C. J., & Kessler, T. M. (2015). Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. The Lancet Neurology, 14(7), 720-732.
Racine, M., Jensen, M. P., Harth, M., Morley-Forster, P., & Nielson, W. R. (2018). Operant learning versus energy conservation activity pacing treatments in a sample of patients with fibromyalgia syndrome: A pilot randomized controlled trial. The Journal of Pain.
Surrena, H. (Ed.). (2010). Handbook for Brunner and Suddarth's textbook of medical-surgical nursing. Lippincott Williams & Wilkins.
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