Nursing Management Case Study
Added on 2021-02-21
13 Pages2991 Words86 Views
Assessment 1 Nursing casestudy
TABLE OF CONTENTSINTRODUCTION...........................................................................................................................1PRIMARY ADMISSION DIAGNOSIS ........................................................................................1NURSING PROBLEM ...................................................................................................................2NURSING MANAGEMENT..........................................................................................................3DISCHARGE PLANNING.............................................................................................................4CONCLUSION................................................................................................................................5REFERENCES ...............................................................................................................................6
INTRODUCTIONInterpersonal care model (IPC) is defined as the health care approach in which varioushealth care professionals works in collaboration with the patient, caregivers, community, andfamilies. The optimised health outcomes are provided when health services are provided to themas per their individual needs (Dunphy and et.al., 2015). The partnership and collaborationthrough IPC assist in providing high quality experience, safety and improved health results ofcommunities as well as low cost services to individuals. The report will provide the diagnosis and nursing management plan for a case study of 68year old patient named Mr. George Orwell. The patient is suffering from chest pain and hashistory of type 2 diabetes, hypertension and other cardiovascular issues. The study will identifythe key nursing problems and suitable interventions. It will also develop a discharge plan for thepatient so that safe and quality care environment can be assured for the patient at home as well.The purpose of this study is to analyse the various stages of cardiovascular care plan throughnursing management and assessment using interpersonal care model.PRIMARY ADMISSION DIAGNOSIS A 68 year old male patient named George Orwell was admitted to hospital for theproblem of chest pain. The patient was conscious and alert but was feeling very anxious. Hecomplained of central chest pain. The key parameters such as respiratory rate, pulse rate andsaturated oxygen level were found to be normal but he was having very high blood pressure. Theblood pressure of Mr. Orwell was recorded as 170/90. The patient has history of type 2 diabetesmellitus, hypertension and Hypercholesterolaemia. 5 years ago he had coronary artery bypasswhile 6 years ago he had history of Anterior myocardial infarction (MI). For the patients withhistory of artery bypass and AI there are higher chances of suffering from angina (Junghans,2015). It is also observed that last year after the death of his wife he lives alone and thus there isno one at home to monitor his medication intakes. The patient is suffering from obesity and is heavy smoker which indicates that there islack of self care management which is essential for the diabetic patient. At the time of admissionthe pitting oedema was also observed in both the legs. Patient takes GTN spray 4 times in a daybut he complained of breathlessness. The patient was feeling sweaty, anxious and very nauseous.The pitting oedema and chest pain can be considered as the critical issue as diabetes and medicalhistory of MI and artery bypass also enhances the risk factor for blood clot or the blockage in1
arteries or veins (Gulanick and Myers, 2016). The leg oedema has association with thecongestive heart failure. The smoking habits and obesity along with the diabetes are the majorrisk factor for chest pain or angina. In addition to this since patient did not like to take fluidmedications it is also possible that skipping of such medication can cause the swelling in bothlegs (Ulin and et.al., 2016). NURSING PROBLEM Along with the psychophysiological changes there are several issues which creates issuesin delivering appropriate nursing care to the patients. The problem becomes more critical andsensitive with the old age people as they need more assistance and care (Burns, Enomoto andMomtahan, 2016). The identification of these nursing problems helps to deliver a more improvednursing management and care plan for the patient. On the basis of primary diagnosis of patientthe two major nursing problems which are identified are as follows: Inappropriate residential care:Mr. Orwell is 68 years old and lives does not have any assistance at homes. Due todiabetes and other medical background he is required to take medications regularly. Howeverdue to age and insufficient monitoring he often does not understand the medications(Muhammad and et.al., 2016). The patient also take reactive medications such as Aspirin. Thus,it is very essential that his food habits must be regulated so that there are no adverse implicationsof the medications (Smith and et.al., 2015). The breathlessness, anxiety and higher age factorsalso enhances the fall risk for the patient. Ineffective management of diabetes: The diabetes has been one of the major nursing problem for Mr. Orwell. Despite havingdiabetes he does not have any self care management plan. As a result of this his weight is notmanaged and smoking habit is also not controlled. The patients with diabetes becomes morevulnerable to the cardiac issues and heart congestion (Staples, 2015). The regular prevalence ofhigh blood pressure can also be the result of his loneliness and health condition. The lack ofsuitable care and monitoring of eating habits and life style of the patient can impose a continuouschallenge to maintain accurate sugar level and healthy life style (Liu, Gerdtz and Manias, 2016).Due to this nursing issues the vulnerability of patient towards angina and heart failure mayincrease. 2
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