Nursing Assignment-Integrated Case Study-Claudia Donaldson

Nursing assignment-integrated case study- Claudia Donaldson
Introduction
Patient-centered care approach is a necessary consideration in nursing practice, that
recognizes and respects the needs of patients and their family and collaborate with them to
engage in care planning (Ignatavicius & Workman, 2015). Patient centered care model respects
patient’s values, needs and experiences while planning and delivering care through the use of
evidence gathering in the clinical reasoning cycle. This paves the way for developing therapeutic
relationship with patient and nurses (Gluyas, 2015). This report applies the principle of patient
centered care to develop a care plan in relation to the case study of Mr. Davis. The care plan is
developed based on the identification of two actual or potential nursing problems in the case
study and the report also gives detail on patient-centered goal for each nursing problems. The
justification for two nursing intervention and care plan related to each goal is also provided.
Nursing Care Plan 1
Nursing Problem 1
Mr Davis is at risk of hypovolemic shock, a condition where a patient is at risk of decreased blood
volume due to blood loss either internally or externally leading to cardiac complications such as
decreased cardiac output and inadequate tissue and organ perfusion. Based on the handover
information, Mr Davis is at risk due to the fact that the femur receives a direct supply of blood from
surrounding arteries and that the fracture will disrupt circulation both to the femur and the surrounding
tissues and lower extremity. In this case study the nursing problem is potentially related to changes in

the heart rate and ventricular filling capacity, as evidenced by tachycardia and hypotension and cooling
of the peripheries.
Nursing Goals
Mr. Davis will maintain appropriate cardiac output, evidenced by stabilization of systolic blood
pressure and heart rate, maintenance of consciousness level and adequate urinary output.
Interventions with rational
Intervention 1
Assess Mr Davis’s observations, including; vital
signs, neurovascular and neurological, pain score
and wound observations. By completing this
assessment at the beginning of the shift a baseline
of information is given in regards to patient’s
current situation allowing for trends to be
identified later throughout the shift should
complication arise. It also provides the nurse with
evidence to create on going observation timing
requirements.
Intervention 2
As Mr Davis is currently Nil By Mouth (NBM)
for upcoming surgical intervention it is imperative
to monitor his fluid status to ensure that he
maintains appropriate hydration and
Expected health outcomes
Health outcome 1
The major health outcome for Mr Davis by
completing regular and thorough observations is
the early identification of complications and the
appropriate implementation of interventions as
required. Based on the evidence gathered during
the initial observations, the timing schedule of
routine assessments will be determined. In the
case study provided, Mr Davis would require
regular observations at a minimum of hourly,
though frequent visual status would be taken
when nursing staff are available.
Health Outcome 2
By the maintenance of appropriate fluid
management, Mr Davis will decrease the risk of
complications related to hypovolaemic shock by
increasing the vascular supply. These include but
are not limited to; maintenance of cardiac output

cardiovascular haemostasis to maximize his
ability to remain stable throughout surgical
intervention and recovery. Mr Davis currently
has Intravenous Therapy (IVT) running and an
Indwelling Catheter (IDC) insitu which will allow
for clear and concise measurement and
documentation of fluid status. By regular
assessment of input versus output throughout the
shift, the nurse is able to determine the
effectiveness of the fluid therapy and identify
potential fluid overload complications.
which leads to appropriate perfusion of organs
including the kidneys which allows for Mr Davis
to preserve his ability to metabolize and excrete
the medications he will receive in theatre for the
surgical management of the femur fracture.
Nursing Care Plan 2
Nursing Problem 1
Mr Davis is experiencing acute and severe pain related to injury sustained in a motor vehicle accident.
Based on the handover information this is evidenced by; pain scores initially at 7/10 and currently 4/10
with PCA intervention, increased respiratory and heart rates and expressive behaviours including
grimacing on movement.
Nursing Goals
Mr Davis will experience a decreased level of pain through the use of pain assessment and
pharmacological intervention; which will be evidenced by improvements within his regular
observations including pain scores of a tolerable level.
Interventions with rational
Intervention 1
An assessment of Mr Davis’ pain would be an
Expected health outcomes
Health outcome 1
Mr. Davis would be able to maintain satisfactory