Inquiry for Chronic Care Care Planning
Case study: Adam Bing
You have commenced your clinical placement at Curtin Hospital on Ward 9A a Medical Ward. Following handover you have been allocated Mr Adam Bing, aged 45 years, admitted earlier this afternoon to Ward 9A for management of his Grade 2 pressure injury.
You have been asked by your buddy nurse to write Adam’s care plan following his admission to hospital. 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 Adam. 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.
A 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.
Handover of Care:
You will need to provide a handover of care for each identified nursing diagnostic statement using ISOBAR.
You will need to include a discharge plan for each identified nursing diagnostic statement.
GORDON’S HEALTH ASSESSMENT: Adam Bing
Client Initials: A.B
Date of Birth: 20/8/1971
Marital Status: Single
Ethnic Group: Australian
Occupation: Employed part-time in IT. Currently on sick leave.
Education: Year 12
Primary Language: English
Usual Health Practitioner: Dr Helen Knowles, Mary Street Practice, Perth
Client has an unkempt appearance, wearing dirty clothes with stains down the front of his shirt, offensive odour, halitosis and inappropriate footwear. Client requires wheelchair for mobilising.
CHILDHOOD / ADULT ILLNESSES
Hepatitis A / B / C
Hypertension: 10 years managed with medication
Hep A / B
Nil previous admissions to hospital
ACCIDENTS / INJURIES
Nil previous accidents/injuries noted or voiced.
Nil known drug reactions.
Paracetamol 1g orally 4-6/24 PRN for pain
Avapro 300mg orally daily mane
Only child. Parents passed away when Adam was 22 years old. Maintained close relationship with extended family after parents passed away. No problems with physical development.
HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN
Reason for seeking health assistance:
Client referred by Dr Helen Knowles for management of Grade 2 pressure injury with partial skin loss on sacrum. “I can’t even see this sore they keep talking about, but believe me, I know it’s there with all the pain I’ve been feeling”.
Client’s perception of usual and current health status:
Client states “I know my weight has been creeping up on me lately. Now with this thing on my back I can’t seem to get out of bed as much as I know I should. Some days I spend the whole day in bed watching TV as it’s just easier”. “My neighbour Mrs Evans sometimes pops in to check on me and to see if I need anything”. “It was Mrs Evans that took me to see Dr Helen, and now I’m here in hospital”.
Single. Neighbour Mrs Evans who lives in same apartment building, visits once a week.
Has no regular social contact since he stopped going to his miniature boating club over the last 12 months.
Usual: Breakfast: cereal, “Whatever’s on sale at the shops, I don’t have those healthy cereals though with no flavour”, cup of coffee, toast; Lunch: “I have been buying those frozen dinners lately and having those for lunch and dinner. Sometimes Mrs Evans will drop in a meal if she bakes extra”; Dinner: “I probably snack too much during the day in between meals to eat dinner. But like I said I will have a frozen dinner or order take away that comes to my door”. Adam is unable to confirm how much water he drinks daily. However states “the kitchen is such a long walk from my room, on days when I can’t be bothered I drink from the mini fridge I have in my room which has soft drinks and those energy drinks I like”.
Current: On restricted diet since admission. Client states “The serves are so small here in hospital, so I have been putting x 2 on all the menu items”. “I’ve asked Mrs Evans to bring in some snacks and soft drinks when she comes in to visit”. “The other nurse said I will have to see the dietician soon which I am not looking forward to”.
Weight: 120 kg (gained 30kg since last check up with GP 12 months ago)
Height: 173 cm
BMI 40.1 kg/m2
Pale, sweaty. Skin turgor <3 seconds. Distinct odour. Unable to remember when last showered, Adam states “I hate to say, but it could have been a week ago”. Grade 2 pressure injury with partial skin loss on patient’s sacrum. Nil signs of infection noted on inspection.
Thin, black/grey, greasy hair. Unable to remember last time he washed his hair. No hair loss.
Long, dirty nails. Client states “I know, I know. I should make more of an effort. I just find it difficult with my weight and sore on my back to get myself into the shower and get clean”. Capillary refill < 2 seconds.
Abdominal distention, striae present. No masses felt on palpation, bowel sounds heard in all four quadrants.
Usual: Bowels open second daily, no dysuria.
Current: “I can’t remember when I last used my bowels, usually I go second daily. I’m pretty certain I went yesterday”.
ACTIVITY AND EXERCISE PATTERN
Usual: Client not involved in any physical activities. No exercise routine.
Current: “The doctor said I may have to see the physiotherapist, I know, I know I need to get up and going more. It’s just hard to get moving, and now with this sore on my back” Currently RIB. Pressure area care every 4/24.
Usual: Complaints of breathlessness on minimal exertion, non-smoker.
Current: No complaints.
Thorax: No scars, AP to transverse diameter ratio 1:2
Lungs: Normal breath sounds heard in all fields, absence of adventitious breath sounds
Usual: Hypertension. No Hx of leg cramps or fainting.
Current: No complaints of chest pain.
Blood pressure: 134/72 mmHg
Spinal Curvature: “S” shaped. Grade 2 pressure injury with partial skin loss on sacrum.
Joints: Bilateral limited range of movement in upper limbs and lower limbs. Pain in lower back. Patient rates pain 8/10. Limited mobility. Requires wheelchair for mobilising.
Pulses: All palpable, Grade 2+
SEXUAL/REPRODUCTIVE HEALTH PATTERN
No current partner. No children.
Usual: 14 hours.
Current: “I have no problems sleeping, even with this sore on my back. Nothing keeps me awake. Even with that new patient over there snoring, I can still sleep”
SENSORY PERCEPTUAL HEALTH PATTERN
Vision: No problems noted.
Touch and pain: Pain in lower back. Current pain score 8/10. Facial grimacing on mobilisation and repositioning.
Taste and smell: Nil changes noted. Halitosis. Teeth discoloured. Unable to state last time teeth were brushed.
COGNITIVE AND PERCEPTION PATTERN
Nil changes noted.
“Not much to say really, I am single, overweight, I know I should lose some of the weight, I just need some motivation to get me going again”. “I know I should be bothered I’m not getting up to shower myself as much as I should. I know I should be exercising more and eating less. I’ll get there”.
COPING AND STRESS PATTERN
Client expresses concern over his limited mobility and grooming, “My weight is affecting my walking. Because I’m not walking I’m staying in bed all day which I think has caused this sore on my back”. “I’ll be ok”.
VALUES AND BELIEFS PATTERN
No strong affiliations or value base.
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