Nursing Assessment Report: Clinical Scenario and Interventions

This clinical portfolio presents a nursing assessment of a 74-year-old female patient in long-term care, focusing on her pressure ulcer, history of left distal femur fracture, atrial fibrillation, and breast mastectomy. The assessment utilizes Gordon's functional health pattern framework to conduct a ho...Read More

Running head: NURSING ASSESSMENT
Nursing assessment
Name of the student:
Name of the University:
Author’s note

1NURSING ASSESSMENT
Introduction:
Registered nurses working in long term care placement have a vital role in ensuring
delivery of safe and ethical care. It is a responsibility for them to deliver patient-centred care in
long term setting so that patients with long-term health issues are adequately supported in the
journey towards health reform and symptom improvement (Eaton, Roberts & Turner, 2015).
This clinical portfolio describes a clinical situation where I have cared for a client in long term
placement who is suffering from pressure ulcer and has a history of left distal femur fracture,
atrial fibrillation and breast mastectomy. The paper will define the method that I used to
complete nursing assessment of the client. The paper also gives an insight into how focussed
assessment tool guides a nurse in planning appropriate interventions for client. The paper also
discusses approach used to meet competencies 1.2 and 1.5 from the domain 1 competencies
mentioned in the Nursing Council of New Zealand.
Nursing assessment using Gordon’s framework:
I decided to conduct nursing assessment of the patient using the Gordon’s functional
health pattern questionnaire. The main advantage of using this framework for assessment is that
helps to conduct holistic assessment and identify both physical as well as social issues affecting
health of client (Edelman, Mandle & Kudzma, 2017). The key results and observations from the
Gordon’s assessment are as follows:
General:
 74 year old female patient
 New Zealand European culture and he was a roman catholic

2NURSING ASSESSMENT
Observation and assessment:
The cultural aspects can be considered to promote cultural sensitivities and respect
patients preference during care delivery.
Health perception:
Patient stated:
 Feels very tired and struggle to do daily activity.
 Hospital admission because of symptom of vomiting and loose bowel, decreased oral
intake and dysurea.
 He has previous medical history included breast cancer, mastectomy, COPD, and left
distal femur fracture
 Unable to daily activities
Observation and assessment:
Her repeated admission to the hospital and being bed ridden might be the cause behind
pressure ulcer as prolonged rest time and being bed ridden increased the likelihood of pressure
ulcer.
Nutrition and metabolic patterns:
 No dietary restriction.
 No special food preferences apart from the fact that she likes to have more salt in food
and does not like pumpkin.
 No problem in swallowing foods
 Takes 1.2 L fluid per day

3NURSING ASSESSMENT
Observation and assessment:
The patient was also inquired regarding any swallowing difficulty as increasing age leads
to physiological changes in swallowing function (Sura et al., 2012). However, the client reported
no difficulty in swallowing. Her fluid intake per day was up to 1.2 litre which is lower than
average daily fluid intake. However, she needs to be educated on proper diet as more salt
consumption is not good for her.
Sleep and rest:
 Sleep pattern has been altered due to excessive pain on the left foot
 Not taking any sedation currently
 Using tramadol tablet
Observation and assessment:
On assessment of patient regarding sleep rest pattern and how well she falls asleep, it was
found that currently her sleep pattern has been altered due to excessive pain on the left foot.
Suzuki, Miyamoto and Hirata (2017) supports that pain is one of the primary causes of chronic
insomnia in older people. Many patients take sedatives to get adequate amount of sleep.
However, the patient has not taken any sedatives. She is taking tramadol to control her pain.
Activity and exercise:
 Extreme difficulty in movement and transfer.
 Two-person assistance for transfer to chair.
 Can move her upper part of the body and right leg, her left leg movement was severely
restricted because of pressure ulcer wound and pain. T

4NURSING ASSESSMENT
 Pain score of 7.
 Hendrick Fall assessment score- 9
 Can wash upper part of the body and feed herself
Observation and assessment:
The above observation reflected risk of fall for patient. I considered conducting fall risk
assessment of patient using the Hendrick fall assessment tool. This is an important tool for
assessment of risk of fall and promoting safety of patient in hospital (Zhang et al., 2015). The
score obtaining for the patient using the Hendrick fall assessment tool was 9 denoting that the
patient was in serious risk of falling and required extra support during hospital stay.
Elimination bowel and bladder:
 Experiences urine incontinence
 On laxatives currently
 Bowel movement normal
 Bristol assessment type 6 moderate bowel movement
Observation and assessment:
She was found be suffering from urinary incontinence and constipation. Both of these
symptoms are linked to age related health issues for client.
Skin condition:
 The Braden score revealed a score of 15.
 . The wound length was 3cm approximately and width was 2 cm.
 The wound looked necrotized indicating signs of infection.

5NURSING ASSESSMENT
 Capillary refill was found to be very slow
 The foot was found to be cyanosed.
Observation and assessment:
The assessment of skin of other parts of the body revealed rashes in thighs and buttocks
indicating sign of fungal infection. Appropriate inspection and assessment is needed to identify
care needs for the patient.
Self-perception:
 Feels bad about her condition
 Does not make contact because of shame
 Able to communicate her needs
Stress tolerance:
 sleep, reading books and watching television to tackle with stress
 Good sensory perception
 Use eye glass for reading and can read small print
Observation and assessment:
When patients suffer from many health issues, they often go through low mood and
depression. Hence, I wanted to examine self-perception of patient regarding her health. The
patient replied that she felt bad about her condition and did not made eye contact because of
shame. However, one positive aspect is that the patient is actively communicating her needs.
This may help her to get treatment and medical attention on time. Other positive point is that she

6NURSING ASSESSMENT
engages in positive activities like sleep, reading books and watching television to tackle with
stress. These are positive coping style that may help her overcome stress (Yu et al., 2016).
Sexuality:
 Husband’s death 4 years ago
 One son, daughter and grand daughter
Observation and assessment:
This indicates that any sexual need is not hampered due to the disease condition
Role and relationship
 She is a widow
 She is a mother, grandmother and friend
Observation and assessment:
She has appropriate family support needed to care for her health and well-being
Values and beliefs:
 Roman catholic
 Like to participate in mass
Observation and assessment:
 This information may help to address cultural needs of client during care delivery.
Two focussed tool for assessment and nursing intervention:

7NURSING ASSESSMENT
While engaging in nursing assessment of the client using Gordon’s functional health
pattern framework, two focussed assessment tool called the Braden scale and the Hendrick fall
assessment tool has helped to plan appropriate nursing intervention for the client. The braden
scale is based on a scoring system that evaluates risk of developing pressure ulcer in patient and
it evaluates risk of pressure ulcer by examination of six domains such as sensory perception,
moisture, activity, mobility, nutrition, friction and sheer. Each of the domain or category is rated
on a scale of 23 points and there are 23 total possible points that can be obtained. A high score of
23 means that the patient is at not no risk for developing pressure ulcer, whereas lowest possible
score of 6 suggest that patient is at high risk of developing pressure ulcer (Osuala, 2014). The
assessment of the patient in the long term care using the Braden scale and considering the six
categories indicated a score of 15. This indicates that the patient is at mild risk of pressure ulcer.
Evidence also suggests Braden scale as a standardized tool to assess pressure ulcer risk
(Sundaram et al., 2016).
In response to the assessment of left foot of the patient using Braden scale, it has been
identified that the patient is at small risk of pressure ulcer. The use of a focussed assessment tool
like Braden scale helped to plan appropriate nursing intervention for client. Positioning and
repositioning of the client has been prioritized to redistribute pressure and minimize shear and
friction forces on the skin. It is planned to reposition the patient after every two hours. Bradford
(2016) gives the evidence that positioning of patient is part of good pressure area care and it is
particularly effective for immobolized and frail elderly patients. During the process of
repositioning, special attention will also be paid to reduce pain in the patient. This is because
persistent pain can increase the likelihood of pressure injury. Hence, to reduce pain on moving, it
is planned to give analgesics like tramadol to patient thirty minutes before repositioning so that

8NURSING ASSESSMENT
no issues occur while repositioning patient.( Berlowitz & Schmader, 2017) This is also necessary
because the patient is currently experiencing pain in the left foot. Another nursing intervention
that is important for patient in relation to skin assessment is prevention of pressure ulcer using air
mattresses. Mattresses with alternating pressure can provide comfort to patient and reduce the
likelihood of developing pressure ulcer (Sauvage et al., 2017).
Another focused tool that has been used during the assessment includes the Hendrick fall
risk assessment tool. A score of 5 or greater is an indication of high risk of fall. The assessment
of the patient using this tool revealed of a score of 9. This denoted that the patient was at high
risk of falling. This tool helped to identify risk of fall in patient and plan intervention that could
provide transfer assistance to patient. The second nursing intervention for the client focusses on
identifying transfer assistance device that could help to reduce fall for patient during hospital
stay. It is planned to take maximum precaution during transferring the patient and transfer
assistance device like use of hoist and appropriate support surface has been planned to reduce
friction and shear forces. Protective barriers like pressure stockings and use of foam pad will also
help reduce fall and its adverse consequences for patient (Osuala, 2014). As the patient is in the
advanced age and suffering from weakness due to multiple illnesses, prioritizing fall
management is even more important for the client (Lannering, Ernsth Bravell and Johansson,
2017). Another nursing intervention that can prevent fall in patient includes conducting
environmental assessment and modifying the environment that are conducive to increase risk of
fall (Pighills et al., 2016). For example, it can involved removing barrier in patient’s pathway
and raising bed railing to reduce the likelihood of fall. This is effective as part of nursing
responsibility to promote safety of patients in care (Nettina, Msn & Nettina, 2013).
Methods used to meet 1.2 and 1.5 of domain 1 competencies for registered nurse:

9NURSING ASSESSMENT
The Nursing Council of New Zealand defines several competencies for nurse while in
practice. The first competency is related to professional accountability that requires nurse to
demonstrate knowledge for accountable practice. The competency 1.2 requires the nurse to
demonstrate the ability to apply the principles of the treaty of Waitangi to nursing practice. This
means considering differences in health and socio-economic status of Maori and non-Maori. As
part of competency 1.2, it is a responsibility for registered nurse to consider cultural sensitivity
and promote cultural safety while providing care to the client (Nursing Council of New Zealand,
2011). While working with my client on long term care placement, I met this competency by
identifying the culture and religion related information of the patient and ensuring that cultural
needs of patient is not compromised during care delivery. As the patient was a Roman catholic, I
asked the patient if any intervention interferes with his cultural needs. I also took the approach to
take informed consent from patient during each clinical decision so that client has control over
his knowledge and customs. I paid attentions to ensure that my clinical decision was agrees to by
the patient too to achieve positive health outcomes. I also create supportive environment for
patient by explaining care needs in the client’s native language.
The competency 1.5 of the domain 1 competencies related to practice nursing in a
manner that the health consumer determines as being culturally safe. To meet this competency,
the application of the principles of cultural safety in nursing practice is important (Nursing
Council of New Zealand, 2011). I fulfilled this competency in long term care placement by
inquiring about cultural preferences of patient during care and respecting individual beliefs,
values and goal of patient. To ensure that patients from different cultural background have
adequate support, I also focused on finding a representative who could meet all cultural needs of
the patient. This step makes patients feel empowered and motivated during hospital stay too.

10NURSING ASSESSMENT
Cultural safety is an essential component within New Zealand nursing and all nurse must strive
to integrate cultural safety principles into practice (Richardson, Yarwood & Richardson, 2017).
Conclusion:
The report summarized the results obtained from nursing assessment of a patient in long
term placement using the Gordon’s functional health pattern questionnaire. It can be concluded
that Gordon’s functional health pattern is an effective framework to conduct holistic assessment
and identify health needs of client. Two focussed tool like the Braden scale and the Hendrick fall
risk assessment tool helped to identify risk of pressure ulcer and risk of fall in the patient during
clinical placement and plan appropriate intervention. The report also gave idea regarding the
importance of competency 1.2 and 1.5 to promote cultural safety and integrate it in clinical
practice in New Zealand.

11NURSING ASSESSMENT
References:
Berlowitz, D., & Schmader, K. E. (2017). Clinical staging and management of pressure-induced
skin and soft tissue injury. UpToDate, Sanfey, H. and Schmader, D.(Ed), UpToDate,
Waltham, MA.(Accessed April 26, 2018).
Bradford, N. K. (2016). Repositioning for pressure ulcer prevention in adults: a Cochrane
review. International journal of nursing practice, 22(1), 108-109.
Edelman, C. L., Mandle, C. L., & Kudzma, E. C. (2017). Health promotion throughout the life
span. Elsevier Health Sciences.
Lannering, C., Ernsth Bravell, M., & Johansson, L. (2017). Prevention of falls, malnutrition and
pressure ulcers among older persons–nursing staff's experiences of a structured
preventive care process. Health & social care in the community, 25(3), 1011-1020.
Nettina, S. M., Msn, A. B., & Nettina, S. M. (2013). Lippincott manual of nursing practice.
Lippincott Williams & Wilkins.
Nursing Council of New Zealand. (2011). Guidelines for Cultural Safety, the Treaty of Waitangi
and Maori Health in Nursing Education and Practice. Retrieved from:
http://www.nursingcouncil.org.nz/Nurses/Scopes-of-practice/Registered-nurse
Osuala, E. O. (2014). Innovation in prevention and treatment of pressure ulcer: Nursing
implication. Tropical Journal of Medical Research, 17(2), 61.

12NURSING ASSESSMENT
Pighills, A., Ballinger, C., Pickering, R., & Chari, S. (2016). A critical review of the
effectiveness of environmental assessment and modification in the prevention of falls
amongst community dwelling older people. British Journal of Occupational
Therapy, 79(3), 133-143.
Richardson, A., Yarwood, J., & Richardson, S. (2017). Expressions of cultural safety in public
health nursing practice. Nursing inquiry, 24(1), e12171.
Sauvage, P., Touflet, M., Pradere, C., Portalier, F., Michel, J. M., Charru, P., ... & Scherrer, B.
(2017). Pressure ulcers prevention efficacy of an alternating pressure air mattress in
elderly patients: E²MAO a randomised study. Journal of wound care, 26(6), 304-312.
Sundaram, V., Lim, J., Tholey, D. M., Iriana, S., Kim, I., Manne, V., ... & Schlansky, B. (2017).
The Braden scale, a standard tool for assessing pressure ulcer risk, predicts early
outcomes after liver transplantation. Liver Transplantation, 23(9), 1153-1160.
Sura, L., Madhavan, A., Carnaby, G., & Crary, M. A. (2012). Dysphagia in the elderly:
management and nutritional considerations. Clinical interventions in aging, 7, 287-98.
Suzuki, K., Miyamoto, M., & Hirata, K. (2017). Sleep disorders in the elderly: Diagnosis and
management. Journal of general and family medicine, 18(2), 61-71. doi:10.1002/jgf2.27
Yu, B., Xu, H., Chen, X., & Liu, L. (2016). Analysis of coping styles of elderly women patients
with stress urinary incontinence. International journal of nursing sciences, 3(2), 153-157.
Zhang, C., Wu, X., Lin, S., Jia, Z., & Cao, J. (2015). Evaluation of Reliability and Validity of the
Hendrich II Fall Risk Model in a Chinese Hospital Population. PloS one, 10(11),
e0142395. doi:10.1371/journal.pone.0142395