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Assessment

Discuss aboout the Nursing care priorities.

Aged adults are considered to be at a high risk of chronic illnesses, a decline in functionality and geriatric syndromes. (Fortney, 2012)  While there is an increase in knowledge about health problems occurring among old adults and their care management, models of coordination are developing, there remains a paucity of information regarding ways of promoting continued growth and wellness in older adult populations. In the 1980s, Miller developed a nursing model for aged adults called the functional consequences theory for promoting wellness. He described functional consequences as the observable effects of risk factors, actions and changes in the age that effectively influence the quality of life in older adults and their day to day activities. (Hunter & Miller, 2016)  Therefore, nurse’s focus and goals should be directed towards addressing such issues hence promoting wellness outcomes for older adults. This model can, therefore, be applied to Mrs. Barbara Green to enhance the promotion of interventions, both short and long term, in improving goals towards preventing a decline in functionality and addressing quality of life concerns.

According to levett-Jones and Hoffman, Clinical reasoning can be described as the process where nurses and other clinicians end up with an understanding of a client’s problem or situation by collecting cues and processing information. (Levett-Jones et al., 2013)  These enables implementation of interventions, evaluation of outcomes and reflection on and learning from the process. In the nursing scenario of Mrs. Barbara Green, the use of clinical reasoning process will enable nurses to deconstruct and respond to the clinical situation she is in. The stages of the cycle include; patient consideration, cues collection, information processing, and issues identification. Goals establishment, action taking, outcomes evaluation and process reflection are also part of the cycle.

Mrs. Barbara’s assessment should include a comprehensive geriatric assessment based on the principles of the nursing process. The assessment tool should be devised to gather information on the medical, functional limitations and psychological capacities of the client. (Boltz, 2012)  The nurse usually begins the assessment when he or she identifies a potential or emerging problem such as the cash of Mrs. Green who has been referred by her general practitioner to the local community health center. The client should be welcomed and introduced to the process while optimum privacy being maintained. Proper rapport helps in easing the client hence establishing trust and enhancing open communication.

Nursing care priorities

Comprehensive history taking is key to an effective assessment. Mrs. Barbara demographic data should be taken such as full names, age, sex, marital status and the source of history and reliability of the historian. (Williamson, Shaffer, & Parmelee, 2013)  In some cases, objective historical data may be challenging to obtain because some are subject to memory incompetence of patients suffering from impaired cognition or the biased data from the caregivers or other family members. It is usually advised to note the identity of the historian of their reliability and objectivity of one’s assessment.

The client's chief complaints should be stated ideally in her words. The history of the presenting illness should also be outlined. This includes the chronological narrative of why she visited the hospital, presence of new symptoms and the aggravating and mitigating factors. In Mrs. Barbara case, she was referred with chief complaints of painful joints, limited movement, constipation, and swollen feet. The duration of the presenting symptoms should be noted. A nurse should note that elderly clients are recognized for giving any combination of nonspecific, independent and minor complaints. Communication barriers, cultural incompatibilities, memory loss, hearing impairment, and depression may lead to the collection of inadequate, unintelligible information from the patient. (Melillo, 2014)

Mrs. Green has a medical history of dry macular degeneration which is an age-related visual disorder where central vision deteriorated gradually. (Kuno & Fujii, 2013)  She also suffered from hypothyroidism which is a hypothyroid state that results from hyposecretion of thyroid hormones. Rheumatoid arthritis and osteoarthritis are also noted as medical illnesses she had suffered. Because elderly patients are usually on numerous medications, they are at relative risk for adverse drug interactions and overmedication hence careful documentation of all medication is essential.


The social and family history of the client are also important in the assessment of the client. For example, living arrangements, access to medical services, transportation, and financial security pose to have a direct consequence on the health results in elderly adults. (Taylor, 2012)  The passing away of a spouse or detachment from an association or community may be correlated with higher rates of mortality and morbidity in older adults. Therefore, the assessment must incorporate an extensive social evaluation. For example, Mrs. Green was previously connected to her family and community, but now her local doctor is very much concerned that she is becoming too isolated.

Her nutritional status and dietary assessment should be checked as per the nutritional health checklist. This is seen by the fact that her local doctor state that she is not eating properly and is losing weight. A complete full physical examination is very important as it provides objective data that may not be given by history taking. Her general appearance, vital signs, skin, head, eyes, lungs, abdomen, extremities, musculoskeletal, neurologic and her female pelvic among other systems should be assessed. (Taylor, 2012)  For example, in the gastrointestinal system she manifests with constipation and the musculoskeletal system there are joint stiffness, swollen joints, and swollen feet. This data will enable in the diagnosis, planning of goals and the outlining of the interventions to be carried out.

Mrs. Green assessment database indicates chief complaints that are much related to her medical history. For example, her medical diagnosis of arthritis makes her exhibit sign and symptoms such as joint pain and stiffness, limited movement, and swollen feet and enlarged joints. Her medical conditions also make her report complains of occasional dizziness and acute pain. Therefore, the nursing care priorities should be to alleviate pain, enhance mobility and support independence. The diagnostic studies may include blood tests and radiographic studies such as x-rays and magnetic resonance imaging (MRI). (Svanborg, 2013)

The top priority nursing diagnosis is acute pain related to the inflammatory process as evidenced by the patient’s verbal report of pain. (Lohrmann, Dijkstra, & Dassen, 2013)  The patient will, therefore, report relief or controlled pain after the implementation of the interventions. The top priority nursing care is to alleviate pain. As seen in the chief complaints from the referral letter, Mrs. Green complains of painful joints in her knee, hip fingers and back which also makes her uncompliant with her drug medications due to pain.  Therefore, by the end of the interventions, Mrs. Green will be able to follow the prescribed pharmacological regimen and also include skills of relaxation and diversional activities in control of pain.


The nurse ought to investigate the reports of pain paying attention to the location and intensity using the pain scale of zero to ten. Precipitating factors and non-verbal cues should also be noted. The rationale is that self-report is normally the prime source of pain assessment in the determination of management of pain. (Song, Prerost, Gonzalez, & Woodin, 2012). The nurse should also suggest that the client assumes a comfortable position in bed or chair while sitting. Bed rest should be promoted but resume movement as soon as possible. This is important because, in severe disease, total bed rest is advisable until improvements are noted hence limiting pain and injury in joints. Immobility may worsen arthritis pain and stiffness.

The nurse should encourage regular changes in position and support client motility in bed hence avoiding jerky movements. This helps prevent general fatigue and stiffness in joints.  (Smith, Ladd, & Pasquerella, 2012) Recommend the patient to use warm bath or shower and also employ moist compresses to the affected joints several times a day. This heat promotes muscle mobility and relaxation, relieving stiffness and decreasing pain. The patient should be encouraged to use stress management techniques such as guided imagery, controlled breathing, biofeedback, and self-hypnosis. These techniques promote relaxation hence providing a sense of control and improving coping abilities. The nurse should also involve the client in diversional activities concerning the client’s situation. This enables the client to refocus her attention, providing stimulation hence enhancing self-esteem and the feeling of overall wellness. Medication should be administered before activities and planned exercises because it lessens muscle tension and promotes relaxation.

In the case of arthritis in Mrs. Green, collaborative interventions are necessary for her management. Early diagnosis and interventions are essential because constant joint damage happens within the first two years. (Flynn & Johnson, 2015)  Therefore, administer medications as indicated which are the mainstay in managing pain, which is the main nursing priority, slow joint destruction and preserve joint function. The nurse administers analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs such as ibuprofen. These drugs help in controlling mild to moderate pain and inflammation by inhibiting production of prostaglandins hence improvement in mobility and function. (Rakel, 2012)  The nurse can also prepare the client for surgical interventions such as synovectomy, joint fusion, and tendon repair. These surgical procedures for corrective purposes are sometimes indicated to decrease pain and promote the functionality of the joints and mobility.


The second priority nursing care is increasing mobility. This is shown by her complaint of limited joint movement and painful joints. The nurse should assist her with an active or passive range of motion activities and exercises when the client can do so. (Rakel, 2012) This helps preserve and improve the functionality of the joints, increase muscle strength and body stamina. The nurse can discuss and provide safety needs such as raised chairs and handrails in showers and toilet hence preventing accidental injuries and falls. The nurse should also consult with occupational and physical therapists and vocational specialist who help in planning exercises and program activities based on client’s needs. They also instruct in strategies in the protection of joints and use of devices of mobility. (Boltz, 2012)

The third priority nursing care is to enhance self-care and self-independence. This is related to the altered visual sensory perception as manifested by the patient’s vision deficit. The patient’s impaired physical mobility may lead to her inability to manage her daily living activities such as bathing, dressing, and toileting. The nurse should help maintain movement and mobility, control of pain and enhance activity programs. This supports emotional and physical independence. The client should be allowed adequate time to perform tasks to their degree of ability hence capitalizing on the client's strengths. This improves their worth and sense of confidence. The nurse may consult with specialists in rehabilitation such as occupation therapist who help in ascertaining assistive devices that match individualized needs. The nurse can also arrange for a consultation with other agencies such as a nutritionist, meals on wheels or home-care service who may provide additional support in home settings. (Exton-Smith & Overstall, 2012)

Conclusion

Promoting self-care independence in elderly adults can enhance their sense of achievement when they finish a task without any aid. It is, therefore, important for caregivers to ensure preservation and promotion of function rather than their decrease in status in old adults with physical limitations. Education to the client on the importance of performing self-care may help them see the benefit of independence. This education will also enable the client to manage their health hence retaining more independence and lessening the need for medical interventions. It is, therefore, vital for the nurse to assist and encourage family members and other care providers to receive knowledge and skills they need to provide care to the patient hence alleviating the patient's stress.

References

Aggarwal, R. & Chugh, P. (2016). Management of Hypothyroidism in Adults. Internationl Journal Of Medical Research Professionals, 2(6)https://dx.doi.org/10.21276/ijmrp.2016.2.6.002

Bolton, J. (2015). Varieties of clinical reasoning. Journal Of Evaluation In Clinical Practice 21(3), 486-489.doi.org/10.1111/jep.12309

Boltz, M. (2012). Evidence-based geriatric nursing protocols for best practice (1st ed.). New York: Springer Pub. Co.

Exton-Smith, A. & Overstall, P. (2012). Geriatrics (1st ed.). Dordrecht: Springer Netherlands.

Flynn, J. & Johnson, C. (2015). Arthritis (1st ed.). Baltimore, MD: Johns Hopkins Medicine.

Fortney, W. (2012). Geriatrics (1st ed.). London: Elsevier Health Sciences.

Hunter, S. & Miller, C. (2016). Miller's Nursing for wellness in older adults (1st ed.). North Ryde, N.S.W.: Lippincott Williams & Wilkins.

Kuno, N. & Fujii, S. (2013). Dry Age-Related Macular Degeneration: Recent Progress of

 Therapeutic approaches. Current Molecular Pharmacology, 4(3), 196-232. https://dx.doi.org/10.2174/1874467211104030196

Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S., Noble, D., & Norton, C. et al. (2013). The

 ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30(6), 515-520. https://dx.doi.org/10.1016/j.nedt.2009.10.020

Lohrmann, C., Dijkstra, A., & Dassen, T. (2013). The care dependency scale: An assessment instrument for elderly patients in German hospitals. Geriatric Nursing, 24(1), 40-43. https://dx.doi.org/10.1067/mgn.2003.8

Melillo, K. (2014). Evaluation of nursing process and outcomes of care utilizing nurse

practicioners to provide health care for elderly patients in Massachusetts nursing homes (1st ed.).

Rakel, D. (2012). Integrative medicine (1st ed.). Philadelphia, PA: Elsevier Saunders.

Smith, S., Ladd, R., & Pasquerella, L. (2012). Ethical issues in home health care (1st ed.).

Springfield: Charles C Thomas Publisher, LTD.

Song, S., Prerost, F., Gonzalez, E., & Woodin, J. (2012). Psychological and physical wellness in

 older adults from the patient perspective. Health, 04(02), 80-87. https://dx.doi.org/10.4236/health.2012.42013

Svanborg, A. (2013). Practical and Functional Consequences of Aging. Gerontology, 34(s1), 11-https://dx.doi.org/10.1159/000212982

Taylor, C. (2012). Fundamentals of nursing (1st ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Williamson, G., Shaffer, D., & Parmelee, P. (2013). Physical illness and depression in older

adults (1st ed.). New York: Kluwer Academic/Plenum Publishers.

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