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Nursing diagnosis, planning, and expected outcomes for patients with impaired tissue perfusion risk

Discuss about the Report for Nursing of Health Care Planning.

Nursing diagnosis

(patient's need)

Planning

(Nursing intervention Required)

Expected Outcome

 Assessment of pain and identification of impaired tissue perfusion risk

Supplying oxygen, educating the patient in the given case scenario about adequate tissue perfusion, promoting the use of CPM and incentive spirometer. The patient should be assessed for the signs and symptoms of impaired tissue perfusion such as restlessness, pallor, decreased blood pressure, Oliguria and edema (Furrow et al. 2014). The implementation of measures for maintaining the adequate tissue perfusion should be carried out effectively (Butcher et al. 2013).

Adequate tissue perfusion

Reduced physical immobility

Assessing and managing mobilization of pain, helping the patient or client with the mobility aids , assisting with ROM exercises to the joints that are unaffected and maintaining accurate positions in the bed while sleeping or lying down. If in case the symptoms become severe, vasopresssors such as dopamine should  be administered for maintaining cardiac output and  adequate perfusion pressure in an efficient manner (Corry et al. 2013).

Improved functioning  position, enhancement in the knee strength and functioning of joint, participation in the daily activities of living (Butcher et al. 2013).

Social functioning

Assisting the patient in the given scenario with the activities of daily living, providing patient centred care for minimizing depression as well as anxiety, enhancing the confidence, motivating and counselling the patient (Frauenfelder, Achterberg and Müller‐Staub 2016).

The patient exhibits improvements in social functioning

Infection risk due to severe pain and reduced mobility

Assessing the skin with respect to its temperature and colour.  The patient should be administered with intravenous fluids such as colloids and crystalloids as prescribed by the physician (Doenges et al. 2016).   The nurse should perform actions for preventing or treating the deficit of the volume of fluid (Gulanick and Myers 2013). The implementation of measures for maintaining the adequate tissue perfusion should be carried out effectively.The patient should also be administered with antimicrobial agents as prescribed by the physician for treating the infection and subsequently decreasing the release of mediators that are responsible for inflammation (Baird 2015).

Healing of wound and preventing erythema (Butcher et al. 2013).

The middle-aged women over 45 to 60 years of age experience menopause and they are not able to produce estrogen (hormone) from their ovaries. Menopause leads to dryness of the vagina and increases frustration. It has also been observed that the women undergoing menopause has a lack of sexual desire (Gulanick and Myers 2013). In the given case scenario, the similar symptoms are prevalent with the patient named Mr. Green. The women having a high body mass index (BMI) are not satisfied as they gain weight; the same is evident in case of the patient in the given scenario. Additionally, when the patient experience chronic illness, they undergo permanent lifestyle alteration, increased dependence, reduced confidence (Doenges et al. 2016).  It has also been observed in most of the cases that there occurs a disruption in the transition of a normal life together with reduced social contacts (Doenges et al. 2016).  As result, it leads to the physiological as well as psychological changes, including irritation (Potter et al. 2016). It is evident in the given case scenario that the patient is facing difficulties in adjusting with her body image.

3. Being a nurse, I will make the patient feel comfortable as well as safe by concentrating on three factors, which includes dignity, comfort and safety.  Before starting any new task, I would take the consent of Mrs. Green and will communicate with her a soft tone of voice. I will be assessing her dependency levels and will maintain her integrity with the best of my ability at the time of dressing and taking shower. I would consider her personal preferences about personal hygiene while providing her with proper treatment. In addition, I would also provide education regarding health and well-being that would help her to maintain her sense of control and minimizing her discomfiture. I will assist the patient in the activities of daily living and will provide a patient centered care for minimizing depression and anxiety of the patient. In addition, I will motivate the patient so that she can gain self-confidence.

4. The two priority needs that should be considered while planning for the discharge of Mr. Green is as follows:

Ensuring that the observations of the patients are within the normal limit and pain has been controlled by oral analgesics (Townsend 2014).

Measuring the degree of mobility and fall prevention- the patient is no more using crutches and walkers, can move freely and there are no signs of wound infection (Ackley and Ladwig 2013).

5. The patient in the given scenario is experiencing menopause. She is also experiencing physiological changes that are mainly associated with menopause. The genital organ of the patient has shrunken, as her body is not able to produce estrogen. In this condition, the women lack sexual desire and there occurs incontinence (Doenges et al. 2016). Mr. Green is highly vulnerable towards chronic illness. She is also not satisfied with her weight gain. It has been observed that in this age, there is a reduction in the rate of metabolism and there muscle tone is disrupted. Prior to experiencing menopausal symptoms, women undergo mental difficulties like as anxiety, depression, mood swings and depression. In addition, when the patients experience chronic illness, they go through permanent lifestyle alteration, increased dependence and reduced confidence (LeMone et al. 2015). It is evident from the given case scenario, that the patient has a poor self-esteem because of aging and reduced physical activity and enhanced dependence for activities of daily living.

Reduced physical immobility and risk of infection

6. The community resource/support service that may be needed by Mrs. Green after her discharge is “The Victorian Rehabilitation centre”. It is a significant characteristic of patients prior to knee arthroplasty. It offers focused therapy through which the the recovery of the patients is enhanced. It comprise of sessions such as different varieties of physical activities, breakfast, shower and dressing and occupational therapy. It also provides the other services such as hydrotherapy, rehabilitation medicine, psychology, physiotherapy, neuropsychology, occupational therapy, speech pathology, social work and exercise physiology. This center has a comprehensive team comprising allied health professionals, rehabilitation physician and nurses. All of them are committed to obtain the premier outcomes of healthcare for the patients as well as their family.

7.

ADMISSION NOTES

DATE:

12/6/14

NAME:

Mr George Grandin

AGE ON ADMISSION:

87 years

GENDER:

Male

RELIGION:

Christian

CULTURE:

Spanish

LIFESTYLE PATTERNS:

The patient undergoes a healthy and nutritious diet at home and regularly consumes multivitamin tablet and supplements for enhancing his strength. He also has a strong social and emotional support from his family and community

COPING MECHANISMS:

George’s family is his support, which helps him to adapt the coping mechanism for aging. A physiotherapist for balance and gait training assessed him and after fall, he is using a walking stick or frame to make his mobilisation easy.

SOCIAL:

The patient has a healthy social life, lives with his wife and daughter; attends church and Spanish community regularly. He has a good support network at home and church

CURRENT HEALTH PRACTICE/NEEDS:

Recently George has undergone a fall, which has prioritized his ambulating, mobilization related health needs, and he is now using a walking stick. However, he is healthy for his age. He needs a pain assessment and care for his bony prominences

ADL ASSESSMENT:

DIET

OUTPUT

MOBILISATION

HYGIENE

DIET:  Self-feeding

OUTPUT: No urinary issues, constipation

MOBILISATION: Mobile, but uses walking stick and frame

HYGIENE: Independent in performing hygiene measures

He has bony prominences on his hips and pelvis, which impose risk of developing pressure ulcers on that area

FAMILY CONCERNS AND NEEDS RE: CLIENT

George’s wife and daughter are concerned about further assistance or care at home, they were present during admission

ADMISSION OBSERVATIONS:

T

P

R

BP

HEIGHT

WEIGHT

BMI

T= 36.1

P= 64

R= 18

BP= 105/68

Height= 181cm

BMI= 18

65 kgs

NURSING NOTES:

(sign off with name, signature and delegation at the end of the notes)

Name

Signature

Delegation

Nursing diagnosis

(patient's need)

Planning

(Nursing intervention Required)

Expected Outcome

Fall prevention (actual)

Risk assessment of his residence, which will involve the elimination of physical, chemical or biological hazards like slippery floor, chemicals or other things that can promote the risk of fall (Agrawal and Chauhan 2012).

Arranging home equipments in such a way, that can promote his ambulance and independence; for instance arranging bed at a low position (Gillespie et al. 2012)

Vision assessment

Strengthening exercise sessions

Health education related to fall prevention 

Reduced risk of fall and enhanced ambulation with increased independence in ADLs, which would also enhance his self-esteem

Risk of developing pressure areas on the bony prominences at hip and pelvis area (potential)

Weekly assessment of his hip and pelvis area for examining the risk of pressure ulcer development

Enhancing his ambulation

Health education related to changing position during bed time (Merom et al. 2012)

Maintaining hygiene and protection from exogenous contamination

Administration of tropical antiseptic on the bony prominence (DiBardino et al. 2012)

Assessing skin integrity and fluid balance

Promoting exercise to keep him active

Reduced risk of pressure ulcer development, enhanced skin integrity, improved ambulation

Severe pain (actual)

Assessment of pain by appropriate pain scale and based on the pain score medication would be prescribed. Referral pain clinic and reduced consumption of paracetamol (Agrawal and Chauhan 2012).

Pain relief and enhanced ability of managing pain

Risk of developing stress related mental disorder (potential)

Stress management sessions, counselling and holistic care for his mental well-being. Due to reduced independence and mobilisation, George’s social networking can be hampered, which can affect his mental status, promoting the development of symptoms like depression, anxiety or isolation, all of which are due to inability of managing stress (Warshawsky et al. 2013). Thus, the stress management sessions would be helpful for encouraging him and teaching him about the management techniques of stress

Empowered and improved mental status. Confusion disorientation related problems would also be overwhelmed, enhancing ambulation, which will also reduce the risk of pressure ulcer development

Meditation and relaxation are two recommended stress management techniques for Mr. Grandin. Meditation is a process, by which a mode of consciousness is being induced, which ultimately promotes relaxation, thereby reducing stress and realizing some benefits of the process. It would be done by sitting in a form of mind-training (Pronovost and Bo-Linn 2012). It might involve development of an emotional state for analyzing any mental response, for instance stress, towards various phenomenon, which is reduced ambulation in Mr. George’s case. On the other hand, relaxation is another method of stress management (Agrawal and Chauhan 2012). There are various relaxation techniques, used for brainstorming and stress relief. For Mr. George, the selection of the techniques should be precise, it should be done considering his physical condition, and age related complications (Moyer 2012 et al. 2012). Listening to soothing music can be a good relaxation technique, which can also help to motivate Mr. George to adapt coping strategies. It has been revealed from different literatures that listening music has significant positive impact upon stress and related symptoms (Agrawal and Chauhan 2012). Deep breathing is another relaxation technique, which can be applied for Mr. George.

10. Using electronic health record or EHR is one appropriate tool, which can be used for collecting and preserving information related to the Mr. Grandin’s health status. In HER tool, all the personal and medical data can be preserved with security. On the other hand, with the help of EHR tool, appropriate health related data can be collected from the patient and patient family, without encountering any data collection related errors (Coleman et al. 2013). In addition, EHR tool helps to reduce the ethical complications or legal issues related to misinterpretations of information, which is usually happen during handwritten admission information collection (Agrawal and Chauhan 2012). EHR tool is now well characterized by the health care system, thus using this tool to collect information would also help the care professionals and patient family to access his health related data at any time they want and monitor any kind of change in care plan. Changed or improved health status, change in medication or care plan can also be monitored through the implementation of this tool (Mirelman et al. 2012).

Poor self-esteem due to aging or chronic illness

11. The key concern in Mr. George’s case is the development of bony prominence in his hip and pelvic areas and the risk of pressure ulcer development. In this context, regular assessment is very important. Thus, the assessment of his bone consistency, bone mineral density is very important, for which multifactorial risk assessment can be used. It would help to evaluate the risk of pressure ulcer development, based on which medications can be prescribed, for hindering the pressure ulcer development (Anderson et al. 2012). Assessment of his skin integrity and fluid intake should be assessed along with the moisture content of skin, as all of these factors promote the development of pressure ulcer and help in worsening the symptoms (Agrawal and Chauhan 2012). Assessment of his diet is also important. Mr. George needs healthy and nutritious diet, for enhancing bone mineral density and maintaining the moisture content in skin. In this context, the nurse should provide proper diet chart, which can help him to increase his BMI and exercise schedule to manage stress and ambulation.

12. Older people, who are admitted in hospital for long-term care, usually have to suffer hospital-related complications, related to hospital environment. The hospital-associated complications have been shown to worsen the health status of older people, which has been highlighted in several literatures. In this context, the risk of developing pressure ulcer is very common phenomenon, especially in case of older people like Mr. George. It is because, older adults residing in a hospital, usually suffers from loneliness and who stays longer period in hospital, usually have chronic illness, which promote their bed ridden condition (Anderson et al. 2012). Long-term bed ridden condition promotes the development of bony prominence, which in turn develops pressure ulcers; if not taken care properly, these ulcers can worsen the health status severely. Another risk factor is fall related injury. Due to long-term hospital stay, depression and confusion can contribute in increasing the risk of fall and related injury. Pressure ulcer or nosocomial infection can also contribute in fall related injuries (Muir et al. 2012).

13. Mr. George can seek help from the Australian community service programs, which are initiated for providing care and support to the older adults, who are suffering from health issues. In this context, the Council on the Aging (COTA) Queensland can help Mr. George. This council provides non-governmental support and involve aged people in different social programs, for empowering them (Muir et al. 2012). A number of events and campaigns are arranged by the community support organization, which can help Mr. George to reduce his social isolation and rehabilitation, like seniors week, grandparent’s day, seniors equity line and many more.  Another community support service is “Falls talk and Fallscape” (Landi et al. 2012). In this community support program, behavioral interventions are used, for encouraging people in adapting fall prevention measures. In addition, documentation of fall related information and web-based trainings are also provided through this community program (Agrawal and Chauhan 2012).

Community resources and support services for patients after discharge

14. Nurses in Australia, have to follow the code of professional conduct, the code of ethics and nursing competency standards, while implementing nursing care activities towards a patient’s well being. In Mr. George’s case, the nurse would also follow the “Code of professional conduct for nurses in Australia” along with appropriate legislations, relevant to the particular case. The most appropriate nursing code of conduct in Mr. George’s case is “Nurses support the health, wellbeing and informed decision-making of people requiring or receiving care” (Nursingmidwiferyboard.gov.au 2016). It has been revealed from George’s history that he has always been maintained a good health before his fall incident. In addition, he is fully alert and oriented during assessment, thus each decision related to his nursing care plan should be consulted with him along with the collection of his consent before implementation of the nursing intervention.

15. The ANMC code of ethics, which is relevant to the given case study, is “In nursing and healthcare, a culture of safety is valued by the nurses”. The rationale for employing this particular code in the case study of George for supporting the expansion of shared knowledge together with understanding then safety and development of processes related to management of risks. It assists in preventing the unfavourable circumstances. The nurses identify the factors in the settings of healthcare that promotes the adverse conditions and construct cultural safety by means of working with the colleagues in an efficient manner.

16. The nurses who are enrolled within the NMBA standards of practice pertinent with the given case study is- “Providing skilled and appropriate care to the patients or clients while promoting their interdependence as well as involvement in making decisions associated with care. The patients such as George who are not able to look after their physical as well as mental health needs can be provided with appropriate care. For a nurse, these standards of practice ensure an active participation as well as autonomy of the patient who is under the care of a nurse. The nurses need to identify the time when the physical and mental health is deteriorated and they should provide appropriate care and support in an efficient manner.

17. The act, which is relevant with respect to the given case study, is “Public health act 2010”. It is related to the maintenance of public health standards for the community as well as for other. The main objectives of this act include the promotion, protection and improvement of public health. Controlling the risks that are associated with public health and promoting the control of diseases, which are infectious in nature. Recognise the steps of local government role for protecting public health.

References

Ackley, B.J. and Ladwig, G.B., 2013. Nursing diagnosis handbook: an evidence-based guide to planning care. Elsevier Health Sciences.

Agrawal, K. and Chauhan, N., 2012. Pressure ulcers: Back to the basics.Indian Journal of Plastic Surgery, 45(2), p.244.

Anderson, R.A., Corazzini, K., Porter, K., Daily, K., McDaniel, R.R. and Colón-Emeric, C., 2012. CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes.Implementation Science, 7(1), p.1.

Baird, M.S., 2015. Manual of critical care nursing: nursing interventions and collaborative management. Elsevier Health Sciences.

Butcher, H.K., Bulechek, G.M., Dochterman, J.M.M. and Wagner, C., 2013.Nursing interventions classification (NIC). Elsevier Health Sciences.

Coleman, S., Gorecki, C., Nelson, E.A., Closs, S.J., Defloor, T., Halfens, R., Farrin, A., Brown, J., Schoonhoven, L. and Nixon, J., 2013. Patient risk factors for pressure ulcer development: systematic review. International journal of nursing studies, 50(7), pp.974-1003.

Corry, M., Clarke, M., While, A.E. and Lalor, J., 2013. Developing complex interventions for nursing: a critical review of key guidelines. Journal of Clinical Nursing, 22(17-18), pp.2366-2386.

DiBardino, D., Cohen, E.R. and Didwania, A., 2012. Meta‐analysis: Multidisciplinary fall prevention strategies in the acute care inpatient population. Journal of hospital medicine, 7(6), pp.497-503.

Doenges, M.E., Moorhouse, M.F. and Murr, A.C., 2016. Nursing diagnosis manual: planning, individualizing, and documenting client care. FA Davis.

Frauenfelder, F., Achterberg, T. and Müller‐Staub, M., 2016. Documented Nursing Interventions in Inpatient Psychiatry. International Journal of Nursing Knowledge.

Furrow, B., Greaney, T., Johnson, S., Jost, T. and Schwartz, R., 2014.Health law. West Academic.

Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C., Gates, S., Clemson, L.M. and Lamb, S.E., 2012. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev, 9(11).

Gulanick, M. and Myers, J.L., 2013. Nursing care plans: nursing diagnosis and intervention. Elsevier Health Sciences.

Landi, F., Liperoti, R., Russo, A., Giovannini, S., Tosato, M., Capoluongo, E., ... & Onder, G. 2012. Sarcopenia as a risk factor for falls in elderly individuals: results from the ilSIRENTE study. Clinical nutrition, 31(5), 652-658.

LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L. and Reid-Searl, K., 2015. Medical-surgical nursing. Pearson Higher Education AU.

Merom, D., Pye, V., Macniven, R., van der Ploeg, H., Milat, A., Sherrington, C., Lord, S. and Bauman, A., 2012. Prevalence and correlates of participation in fall prevention exercise/physical activity by older adults.Preventive Medicine, 55(6), pp.613-617.

Mirelman, A., Herman, T., Brozgol, M., Dorfman, M., Sprecher, E., Schweiger, A., ... & Hausdorff, J. M. 2012. Executive function and falls in older adults: new findings from a five-year prospective study link fall risk to cognition. PloS one, 7(6), e40297.

Moyer, V.A., 2012. Prevention of falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 157(3), pp.197-204.

Muir, S.W., Gopaul, K. and Odasso, M.M.M., 2012. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age and ageing, 41(3), pp.299-308.

Nursingmidwiferyboard.gov.au. 2016. Nursing and Midwifery Board of Australia - Professional standards. [online] Available at: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx [Accessed 1 Sep. 2016].

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A., 2016. Fundamentals of nursing. Elsevier Health Sciences.

Pronovost, P.J. and Bo-Linn, G.W., 2012. Preventing patient harms through systems of care. Jama, 308(8), pp.769-770.

Stuart, G.W., 2014. Principles and practice of psychiatric nursing. Elsevier Health Sciences.

Townsend, M.C., 2014. Psychiatric mental health nursing: Concepts of care in evidence-based practice. FA Davis.

Warshawsky, N., Rayens, M.K., Stefaniak, K. and Rahman, R., 2013. The effect of nurse manager turnover on patient fall and pressure ulcer rates.Journal of nursing management, 21(5), pp.725-732.

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