Case Study: Patient Assessment and Care Planning for Miss Violet Paterson

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Medical Surgical Nursing
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Consider the patient
In this case study, case of Miss Violet Paterson is being discussed. She is 77 years old and
admitted to hospital due to Acute Myocardial Infarction (AMI). She is also associated with
conditions like hypertension and osteoarthritis. Her hypertensive condition and pain are
impacting her activities of daily living. Her condition is worsening because she is staying
alone and family members are not there to take care of her.
Patient assessment
Medial assessment for Violet need to be carried for three conditions such as cardiovascular
condition, pain and risk of fall. For carrying out holistic assessment for Violet, clinical
reasoning cycle is useful. From the provided case study of Violet, her information was
gathered. Information provided in the case study demonstrated that she was suffering through
multiple conditions such as myocardial infraction (MI) and osteoarthritic pain. Moreover, she
was also having history of hypertension. Collected information need to be processed for the
holistic assessment of clinical condition of Violet (Levett-Jones, 2017). Both osteoarthritic
pain and hypertension remain sustained for the longer duration. Hence, it was interpreted that
both the hypertension and osteoarthritic pain related to cardiovascular condition and pain
respectively need to be monitored on the regular basis. Moreover, in the provided case study
it was also mentioned that it was difficult for her to meet daily living needs. Furthermore, she
was staying alone in her apartment. Her age (77 yrs), staying alone in the apartment and
difficult to meet daily living needs indicates fall of risk in case of Violet. Hence, collection of
information and processing of clinical information in case of Violet indicated that her
condition required to be assessed for cardiovascular condition, pain and fall of risk (Levett-
Jones, 2017). Normal blood pressure in adults should be 120/80 mmHg and pain score
should be 0 on VAS pain scale. However, in the provided case study information, exact
values for the hypertension and pain score were not provided. Information related to blood
pressure values and pain scale would have been useful in assessing extent of deviation from
the normal values. Hence, blood pressure was measured using sphygmomanometer and pain
was measured using visual analogue scale (VAS) (Vischer and Burkard, 2017; Breivik,
2016). Osteoarthritic pain might lead to risk of fall in case Violet. Risk of fall in Violet was
assessed through following falls history, medication review, physical examination and
functional and environmental assessments.
Early assessment of cardiovascular condition, pain and risk of fall would be helpful in
planning suitable intervention for Violet. Recording of exact blood pressure would be helpful
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administering correct medication with the exact dose and duration. Measurement of exact
pain scale also would be helpful in administration of suitable medication and planning for
suitable physical exercise. Assessment of fall risk would be helpful in planning fall
prevention strategies for Violet. It is necessary to perform combined assessment of pain and
risk of fall in Violet because these two conditions are interrelated (Vischer and Burkard,
2017; Breivik, 2016).
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Task 2: Care planning
Nursing Care Plan: Violet
Nursing problem: Risk of peripheral neurovascular dysfunction
Underlying cause or reason: Peripheral neurovascular dysfunction might occur due to cardiovascular conditions like myocardial infraction and
hypertension. Violet was associated with both of these cardiovascular conditions.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To monitor and assess
peripheral
neurovascular
dysfunction and to
maintain normal blood
circulation in the
peripheral area of
body.
Assess Violet for individual risk factors
like trauma associated with the extremities
which might lead to internal tissue damage,
immobility and sedentary lifestyle.
Record positioning of the casts in the head.
Carry out neurovascular assessment in
Violet if she is immobilised due to any
other factor.
Enquire to Violet about localised pain,
discomfort and inform to nurse about the
numbness, tingling and pain at rest or
during movement.
It would be helpful in the identification
of the circulation insufficiency and
occlusion (Ladwig, Ackley, and Makic,
2016).
It would be helpful in recognizing
probable pressure on the tissues
(Swearingen, 2015).
It would be helpful in the future
comparisons (Ladwig, Ackley, and
Makic, 2016).
It would be helpful in identifying
abnormalities (Swearingen, 2015).
Maintain normal functioning in terms of
sensation and movement in the routine range
of Violet.
Participate in all the normal activities.
Establishing signs and symptoms; hence
suitable intervention can be planned in
Violet.
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