Complex Patient: Plan of Care

Your Patient Plan of Care is to be completed on the template provided on UTSOnline. This is to be submitted with your individual written report as an appendix. An appendix goes at the end of the assignment, after the reference list.There are two case studies provided – choose one of these case studies. That is, either Alice McCallum or Christopher Collins.

CASE STUDY – Alice McCallum

Location

Medical ward

Introduction

74yr old female Alice McCallum was admitted 3 days ago following referral form her GP with confusion and falls risk due to hyponatraemia. On admission GCS was E4V4M6 with associated generalised muscle weakness and bilateral leg spasms.

Situation

Improved significantly with IV 0.9% Sodium Chloride with nil motor dysfunction and GCS E4V5M6. Over the past hour the patient has deteriorated with increased confusion and drowsiness GCS E3V4M6.

Background

PMH: T2DM, Hypertension

Drugs: Metformin 1g tds, Bendroflumethazide 2.5mg od (withheld at present)

Allergies: Nil

Social: Lives alone. Widowed for 10 years. 2 daughters, one lives nearby the other lives in UK.

Assessment/Observations

A – patent. Talking in complete sentences

B – RR 25, Sp02 93% on RA, bilateral equal air entry, nil adventitious sounds on auscultation, CXR clear. Mild increased WOB

C – HR 135, BP 98/60, CRT 4 secs, cool peripheries,

D – GCS 13 (E3, V4, M6). Confused to time and place, PEARL, Pain 0

E – IVC looks swollen, inflamed and red. Painful to touch. Appears a bit shivery. Temp 38.6. Nil other skin tears or breakdown. Patient is visibly thin. BMI 19.

F – IVF continue at 80mls/hr. Poor oral intake. FBC shows – +ve balance over last 12 hours. Urine output 150mls over 8 hours.

G – BGL 15mmoLs via finger prick.  Ketones via finger prick – 0

Investigations & results

FBC – WCC 18.3 x 109/L., Hb 147, Platelets 367 x 109/L.

U&E’s – Na 139, K 3.8, U 11.2mmol/L, Cr 142micromol/L,  Glucose 15.6, HbA1c 42mmol/mol (6%)

CXR – NAD

ABG – pH 7.29, PaCO2 21, PaO2 68, HCO3 18, BE –4.2

Lactate – Lactate 4.7mmol/LCASE STUDY: Christopher Collins

Location
Surgical ward

Introduction
Christopher Collins, is a 54 year old, male who was diagnosed with early-stage osteoarthritis in the left knee, causing pain and affecting mobility. Surgery was planned to take weight/pressure off the damaged side of the knee joint and therefore relieve pain and also help improve joint function.

Chris was admitted for a left high tibia knee osteotomy 5 days ago. A plate and screws were used to stabilise the tibia as part of the procedure.  Antibiotics were given by the anaesthetist on anaesthetic induction.  He had an uneventful post-operative period and was discharged two days later. Chris was discharged with non-steroidal anti-inflammatory medication for pain relief, non-weight bearing on crutches and fitted for a supportive knee brace until his planned outpatient review in two weeks time.

Situation
This evening Chris re-presented at the ED. Complaining of pain at incision site, nausea and feeling shaky/shivery.  Wound site left knee, sutured, skin appears ‘tight’, shiny and red. There are several small areas were dehiscence is evident with pus present. Oxygen therapy has been commenced.

Background

PMH: Osteoarthritis, asthma since child hood

Drugs: NSAID, Ventolin, Seretide accuhaler

Allergies: Nil known

Chris is a non-smoker and regular swims (3-4 times a week) and occasionally participates in kayaking.

Assessment/Observations:

A – patent

B – RR 29, Sp02 94% on 60% oxygen, equal air entry, nil adventitious sounds on auscultation, no mucous or sputum production, chest is clear. Verbal report of feeling breathless

C – HR 135, BP 98/57, cool peripheries, temp 38.9oC

D – GCS 15, PEARL. Patient states that he feels dizzy and ‘vague’. Pain score – left knee 7/10

E – Wound site left knee, sutures in situ, skin appears ‘tight’, swollen, shiny and red. Warm to touch. Several areas of dehiscence with pus present

F – IV cannula inserted

G – Glucose 5.1. Nil hx diabetes

Investigations & results

FBC – Hb 142g/l, WBC 18.4 x 109/L., Platelets 276 x 109/L.

U&E’s – U 5.4, Cr 78, Na 141, K 4.2, Glucose 5.1

CXR – normal

ABG – pH 7.25, PaCO2 21, PaO2 80, HCO3 18, BE – 4.0

Lactate – 5.3 mmols / LNursing Care Plan Template
In the care plan template provided, identify 4-6 actual or potential physiological patient problems.
Identify all objective and subjective patient assessment data which supports your clinical reasoning in selecting these issues (i.e. how do you know that this is a problem for this patient?).

• This should be specific assessment data e.g. SBP 88mmHg instead of just saying ‘hypotensive’
Identify the optimal outcome that your patient should achieve before they are discharged.

• This should be a specific target that is appropriate for your specific patient e.g. SBP 110-130, urine output > .5mls/kg/hr, GCS 15/15, etc.

Do not include nursing interventions in the template.

Problems may be:

• actual health problems: a health problem that is currently present or occurring and needs intervention to either end or reverse its effects. There will be patient signs and/or symptoms that support the manifestation of the problem.

Examples:
Dehydration due to ……..
Wound infection related to ……
Acute pain related to ….
Impaired skin integrity due to ….
Inadequate tissue perfusion related to……..• potential health problems: a health problem which has not yet occurred, however based on assessment items there is a risk that the patient may develop this problem if no interventions or prevention measures are initiated.
Example:
The patient is ‘at risk of’ falls due to …
The patient is ‘at risk of’ developing a DVT due to….
The patient is at risk of infection due to………

For potential health problems, please consider that you are identifying the risk based on evaluation of the data you have been given in the case study. As such, the assessment data will be what puts the patient at risk rather than the assessment data the patient would have if they had this problem as an actual problem. For example, the assessment data for an actual DVT will be redness, swelling, pain, heat while the assessment data for a potential DVT might be reduced mobility, low BP, activation of inflammatory response.

Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.Type: Nursing Care Plan Report

From your nursing care plan template select 2 physiological problems. These may be actual problems, potential problems or one of each. Do not select psychosocial problems as you will not be able to discuss the pathophysiology of these.

For each of your chosen problems:
Explain the pathophysiology and how this relates to the patients clinical presentation. I.e. What is happening in the body to cause the signs and symptoms that the patient has?

Identify the key nursing interventions required specifically to treat or prevent the problem you have chosen. These interventions should be supported by contemporary clinical guidelines, policies and high quality best-practice evidence. Nursing interventions should include a rationale supported by evidence. Nursing interventions may be
– Independent interventions – nurse led, nurse initiated
– Collaborative interventions – with other members of the multidisciplinary team
– Dependant interventions – for example dependent on a doctors order
These interventions should focus just on interventions which will specifically treat or prevent your chosen problems. Please do not include general nursing care which would be applicable here, or interventions which are required for all care (i.e. there is no need to identify obtaining consent, hand hygiene, etc. as this is required for all nursing interventions always). You do not need to describe the intervention, just state what you would do and why (not how you would do it).Identify the intended goals of care and patient outcomes for your problem, considering how you would evaluate this. I.e. what do you want to achieve for your patient specifically, how will you measure the patient’s progression towards this goal and how often will you take these measurements?

Include specific outcomes here appropriate for your patient. The idea is that if someone were to read your plan of care without knowing the patient they would still be able to achieve patient specific goals. For example, your patient might have a history of COPD with CO2 retention and the target oxygen requirements would be 88-92%. Instead of your outcome being ‘satisfactory oxygen saturations’ you should specify ‘oxygen saturations of 88-92%’. Instead of saying “acceptable BP” as an outcome, identify what range you want the BP to be in for your patient.

As this is a formal academic report you should include

– an introduction: identify which patient case study you are using and the purpose/direction of your report e.g. \\\”… This report will discuss compartment syndrome and surgical wound breakdown as two actual problems experienced by Mr. Smith. The pathophysiology of these conditions will be outlined along with nursing interventions required to treat these problems…\\\”

– a conclusion: 1 or 2 sentences only which sum up your work. The conclusion should not include references as it is a summary of your ideas only.
– at a third year BN level, for a 2000 word report you should have at least 20 high quality sources of evidence