Discuss about the Health Assessment and Nursing Care Plan.
The objective and subjective data on Kevin Jones demonstrates that the patient has a combination of mental and physical issues that need to be addressed in his care plan. Such information was generated from the physical examination that the practitioner conducted, direct observations made, interviews carried out, as well as the analysis of the patient’s medical history.
In terms of mental health, Kevin is worse-off because he needs an immediate support. His mental health is not okay because he has challenges that have been bothering him all along. From his medical history, it was deuced that the patient had suffered from depression and anxiety. These are serious mental disorders that caused a lot of problems to this patient and barred him from leading quality and stress-free life. With his advanced age, Kevin should not expose himself to such conditions because they do not mean well for his health. His history also proved that Kevin has been an alcoholic. This was also a serious issue because it does not mean well for his advancing age and vulnerable status.
The data revealed that the patient currently has mental problems which have been hindering him from leading a normal, quality, and healthy life. Topping the list of these problems is anxiety. From the observations made by the medic, it was established that the patient has a feeling of frustration. The way in which he communicated with the staff demonstrated that the patient has emotional outbursts ad gets easily irritated. At the same time, he has a slurred speech that hinders him from communicating well with the people around him. The patient’s poor mental state of health is attributed to two factors. One, he has not been getting a social support from the people around him. He lives in isolation because everyone including his children is not around to care for him. He does not get along with his daughter-in-law who seems to be the only person available to offer him the necessary support. Secondly, the patient is living in despair. He is worried about his dead wife, past life as well as properties. All these definitely contribute towards the deterioration of his mental health.
The subjective and objective data affirmed that Kevin has problems with his physical health. His medical history reveals the patient had been diagnosed with stroke. That still poses a challenge to the patient because he is currently having a paralysis on his right side. Unfortunately, because of his immobility and poor physical health, the patient cannot effectively handle this condition because he keeps on forgetting which side of his body he leans on. Meaning, without a proper support, the patient might not cope-up with this condition.
Kevin also suffers from (R) lower lobe pneumonia. This conclusion was arrived at after analyzing two sets of data. First, it was made after analyzing the medical history of the patient. Just a few days ago, Kevin has been complaining of body aches, malaise, taking of little fluids, loss of appetite, chills, flushed skin, fever, greenish yellow sputum, and chronic cough. From the physical examination, it was established that the patient had diminished breath sounds, wheezes on auscultation, O2 sats- 93%, P 90, resp. rate-24/min, BP-90/60, and temperature of 38.3. The patient also has a problem with vision and swallowing. Apart from his weight loss, the patient has recorded increased blood urea nitrogen and urine concentration. He has erratic bowels, produces dry and hard stool. He also has a dry mucous membrane and skin is dry.
From the data collected, Kevin has a problem with his physical and mental health. His social life has partly contributed to the problem. Socially, Kevin is worse-off because there is disconnect in his life. First and foremost, the patient has been living in isolation because he is not in touch with his family members and relatives. His children are not able to give him the required support because they are too committed and do not have enough time to support him as expected. This has negatively impacted on his social life because it is as if he is living a solitude life. His advanced age and limited financial muscle has made him to lose independence because he only has to rely on other people for support, something that is not guaranteed. The patient’s social life has also been engulfed in depression and anxiety. He is not socially-fit because he keeps on worrying about his past life. The death of his wife 13 years ago has been a bit impediment to his health because it subjects him to lots of worries. That is why he is emotionally-unstable and cannot relate well with anyone including the healthcare practitioners who are responsible for his treatment.
When Kevin came to the facility, he was thoroughly examined. His assessment was done in three ways. First, the medic assessed his medical records of the patient to ascertain his medical history. Besides, it was performed by carrying out an interview to get a first-hand account of the patient’s health. However, this was not smoothly-done because the patient has a blurred speech. Finally, the assessment was done by carrying out a test to examine the patient’s body. These assessments revealed a lot about the patient’s health.
The data revealed that the patient currently has mental problems which have been hindering him from leading a normal, quality, and healthy life. Topping the list of these problems is anxiety. From the observations made by the medic, it was established that the patient has a feeling of frustration. The way in which he communicated with the staff demonstrated that the patient has emotional outbursts ad gets easily irritated. At the same time, he has a slurred speech that hinders him from communicating well with the people around him.
The subjective and objective data affirmed that Kevin has problems with his physical health. Kevin also suffers from (R) lower lobe pneumonia. This conclusion was arrived at after analyzing two sets of data. First, it was made after analyzing the medical history of the patient. Just a few days ago, Kevin has been complaining of body aches, malaise, taking of little fluids, loss of appetite, chills, flushed skin, fever, greenish yellow sputum, and chronic cough. From the physical examination, it was established that the patient had diminished breath sounds, wheezes on auscultation, O2 sats- 93%, P 90, resp. rate-24/min, BP-90/60, and temperature of 38.3. The patient also has a problem with vision and swallowing. Apart from his weight loss, the patient also has a dry mucous membrane and skin is dry. He recorded increased blood urea nitrogen and urine concentration. He has erratic bowels, produces dry and hard stool.
Nursing Diagnosis
Evidenced by:
Evidenced by:
Evidenced by:
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Nursing diagnosis: 1 |
Pneumonia |
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Evidenced By: |
Chronic cough that the patient has been experiencing. The cough has greenish yellow sputum. The examination also revealed that the patient has got a chest pain. There was also a breathing difficulty because the respiration rate was 24/minute. At the same time, the patient has a blood pressure of 90/60. |
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Goal & Time Frame: |
The patient is expected to show an improvement in the tissue perfusion. This will have to be proved by the evidence of improved laboratory values. It will be a short-term goal that will be expected to be accomplished within 24 hours (Torres, Sibila, Ferrer, Polverino, Menendez, Mensa & Niederman, 2015). At the same time, the patient is expected to demonstrate a long-term improvement on the verbalization abilities, energy levels and lab values. The long-term goal will be expected to be realized after at least one week. |
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-The nurse will have to assess all the factors that cause the infection and contribute to its occurrence. -The nurse will closely work with the patient and request him to keep on changing his position after every 2 hours (Micik, Besic, Johnson, Han, Hamlyn & Ball, 2013). -The nurse will assist the patient and give him the necessary instructions to follow in order to cease smoking and increase the flow of blood in the body -The nurse will have to help the patient to engage in physical exercises by supporting him to walk and move around whenever necessary |
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Rationale: -The rationale for the assessment of the causative factor of the disease is that it will enable the nurse to understand all the causes in order to come up with an accurate decision on how to help the patient to deal with the disease by addressing each of the causes (Mulholland, Carlin, Duke & Weber, 2014). -The rationale for the changing of patient’s position is that it will help in improving the rate of flow of blood throughout the body The rationale for the stoppage of smoking is that it will help in improving the flow of blood and eliminate any chances of vasoconstriction that might escalate the disease and render the patient defenseless (Postma, et al., 2015). -The rationale for the engagement in physical exercises is that it will eliminate the stasis of the blood and increase its flow. |
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Evaluation of Care: -The success of these interventions will have to be assessed to determine the extent to which they are achieved. Physical examination and direct observation will have to be conducted to determine if the patient improves as far as physical mobility, rate of blood flow, and the rate of breathing is concerned. |
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Nursing diagnosis: 2 |
Stroke |
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Evidenced By: |
-Paralysis Hypertension -Difficulty in swallowing (Kirchhof, Breithardt, Camm, Crijns, Kuck, Vardas & Wegscheider, 2013). -Emotional difficulties |
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Goal & Time Frame: |
-The short and long-term goals of this plan is to eliminate paralysis, difficulties in swallowing, and correct the emotional behaviors of the patient (Ignatowski, Spengler, Dhandapani, Folkersma, Butterworth & Tobinick, 2014). |
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Nursing Interventions |
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-Exercising regularly -Controlling body weight -Controlling High Blood Pressure (Demaerschalk, et al., 2016). -Lowering the quantity of cholesterol in the diet |
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Rationale: -The rationale of these interventions is to maintain a healthy body weight; regulation of the blood pressure; and removing paralysis of the body (Viscoli, et al., 2014). |
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Evaluation of Care: The extent to which the intervention’s objectives are achieved will be evaluated by assessing the changes and improvements accomplished in controlling the body weight, blood pressure, and paralysis. |
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Nursing diagnosis: 3 |
Depression |
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Evidenced by: |
-Depressed moods -Weight loss -Irritability -Appetite changes (Carlbring, Lindner, Martell, Hassmén, Forsberg, Ström & Andersson, 2013) -Withdrawal physical immobility -Anxiety -Slurred speech |
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Goal & Time Frame: |
-the short and long-term goals of this plan will be to ensure that the patient improves his mental health and overcomes the problems of anxiety, speech difficulties, appetite loss, irritation, and weight loss (Porter, Bowie, Jordan & Malhi, 2013). |
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Nursing Interventions: |
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-The nurse to provide support to the patient and be ready to discuss many issues such as the causes, risk factors, dangers, management and the solution that should be applied to deal with the condition. The support should not only be provided to the patient, but to the close family members as well (Baer, 2015). They should also be involved in the management of the patient’s condition. -The psychiatrist should provide an appropriate therapeutic service to the patient. Cognitive Behavioral Therapy (CBT) is the most appropriate for the patient (Carlbring, Lindner, Martell, Hassmén, Forsberg, Ström & Andersson, 2013). -The nurse should prescribe appropriate medications to the patient. |
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Rationale: (reasons) – References needed to validate nursing interventions -The rationale for providing support to the patient is that it will equip him with all the information that he needs to know about the causes, risk factors, dangers, treatment, and management strategies for the depressive condition experienced (Carlbring, Lindner, Martell, Hassmén, Forsberg, Ström & Andersson, 2013). It will also inform the family members and encourage them to closely-work with the patient by giving him the social support that he requires. -The rationale for the administration of the antidepressant drugs is that it will facilitate the speed of recovery and enable the patient to restore his deteriorating mental health (Schlaepfer, Bewernick, Kayser, Hurlemann & Coenen, 2014). -The rationale for CBT is that it will improve the quality of management of the disorder and enhance the speed of recovery. |
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Evaluation of Care: -The extent to which all these interventions will have achieved will be measured by determining the changes in the patient’s mood, anxiety levels, and speech, both in the short and long-terms. |
References
Baer, R. A. (Ed.). (2015). Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications. Elsevier.
Carlbring, P., Lindner, P., Martell, C., Hassmén, P., Forsberg, L., Ström, L., & Andersson, G.
(2013). The effects on depression of Internet-administered behavioural activation and physical exercise with treatment rationale and relapse prevention: study protocol for a
randomised controlled trial. Trials, 14(1), 35.
Carlbring, P., Lindner, P., Martell, C., Hassmén, P., Forsberg, L., Ström, L., & Andersson, G.
(2013). The effects on depression of Internet-administered behavioural activation and physical exercise with treatment rationale and relapse prevention: study protocol for a randomised controlled trial. Trials, 14(1), 35.
Demaerschalk, B. M., Kleindorfer, D. O., Adeoye, O. M., Demchuk, A. M., Fugate, J. E., Grotta, J. C., … & Saposnik, G. (2016). Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for Association. Stroke, 47(2), 581-641.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
Ignatowski, T. A., Spengler, R. N., Dhandapani, K. M., Folkersma, H., Butterworth, R. F., & Tobinick, E. (2014). Perispinal etanercept for post-stroke neurological and cognitive dysfunction: scientific rationale and current evidence. CNS drugs, 28(8), 679-697.
Kirchhof, P., Breithardt, G., Camm, A. J., Crijns, H. J., Kuck, K. H., Vardas, P., & Wegscheider, K. (2013). Improving outcomes in patients with atrial fibrillation: rationale and design of the Early treatment of Atrial fibrillation for Stroke prevention Trial.
American heart journal, 166(3), 442-448.
Micik, S., Besic, N., Johnson, N., Han, M., Hamlyn, S., & Ball, H. (2013). Reducing risk for ventilator associated pneumonia through nursing sensitive interventions. Intensive and Critical Care Nursing, 29(5), 261-265.
Mulholland, K., Carlin, J. B., Duke, T., & Weber, M. (2014). The challenges of trials of antibiotics for pneumonia in low–income countries. The lancet Respiratory medicine, 2(12), 952-954.
Porter, R. J., Bowie, C. R., Jordan, J., & Malhi, G. S. (2013). Cognitive remediation as a treatment for major depression: a rationale, review of evidence and recommendations for future research. Australian & New Zealand Journal of Psychiatry, 47(12), 1165-1175.
Postma, D. F., Van Werkhoven, C. H., Van Elden, L. J., Thijsen, S. F., Hoepelman, A. I.,
Kluytmans, J. A., … & Oosterheert, J. J. (2015). Antibiotic treatment strategies for community-acquired pneumonia in adults. New England Journal of Medicine, 372(14), 1312-1323.
Schlaepfer, T. E., Bewernick, B. H., Kayser, S., Hurlemann, R., & Coenen, V. A. (2014). Deep brain stimulation of the human reward system for major depression—rationale, outcomes and outlook. Neuropsychopharmacology, 39(6), 1303.
Torres, A., Sibila, O., Ferrer, M., Polverino, E., Menendez, R., Mensa, J., … & Niederman, M.(2015). Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: a randomized clinical trial. Jama, 313(7), 677-686.
Viscoli, C. M., Brass, L. M., Carolei, A., Conwit, R., Ford, G. A., Furie, K. L., … & Parsons, M.
(2014). Pioglitazone for secondary prevention after ischemic stroke and transient ischemic attack: rationale and design of the Insulin Resistance Intervention after Stroke Trial. American heart journal, 168(6), 823-829.
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