NUR250 Semester 1 2019: Care Plan for Violet Paterson Post-AMI

This report presents a care plan for Miss Violet Paterson, a 77-year-old woman admitted to the hospital following an acute myocardial infarction (AMI). The care plan addresses her history of hypertension and osteoarthritis, emphasizing a holistic approach to nursing care. It details the importance of thorough nursing assessments, including admission, shift, and focused assessments of the respiratory and circulatory systems. The report discusses nursing diagnoses, including actual diagnoses, risk diagnoses, and health promotion diagnoses, focusing on the patient's individual needs and circumstances. It also highlights the significance of multidisciplinary care and patient education at the time of discharge, particularly regarding medication management, dietary restrictions, and symptom recognition. The report concludes by identifying the various members of the healthcare team involved in the patient's care, emphasizing the collaborative approach required to optimize patient outcomes.

Running head: CARE OF A PATIENT WITH A MEDICAL CONDITION
CARE OF A PATIENT WITH A MEDICAL CONDITION
Name of the Student
Name of the University
Author note

1CARE OF A PERSON WITH A MEDICAL CONDITION
The given case study is about an old woman of 77 years of age named Miss Violet
Paterson. She was suffering from acute myocardial infection and was admitted to the ward.
Currently her condition is good, her health condition was improved. After analysing the history it
was found as she was suffering from hypertension and osteoporosis. During the last few months,
the conditions of osteoporosis and blood pressure increased a lot and these things even affected
her daily routine. She lives alone in the 3rd floor of an apartment with no one else except her cat.
The old woman was admitted to the hospital and there she is supposed to get all the care
from the nurse. The care plan of the nurse provides all the healthcare benefits needed by the
patient. The main focus of this care plan is to provide a standard and holistic care plan. The care
plan identifies the problems that the patient is suffering (Westra et al., 2015).
The nurse must do proper assessment of the lady, the medical reports that the nurse has till
now and also the diagnostic reports. The nurse must assess the physical conditions of the patient
along with the psychological conditions, sexual, emotional, cultural, spiritual, functional and age.
The other areas which need to be considered by the nurse are the economic conditions and the
environmental conditions (Hoffman, 2015). The old lady lives alone and also her economic
condition is not so good. The nurse must emphasize on this.
The nurse must outline the outcomes expected by the patients. She must make sure whether
the disease can be progressed within a short period of time or a long period of time.
The nurse must include the nursing documentations in the plan. Evaluation of the
documents are also needed for the nursing interventions (Johnstone & Hutchinson, 2015).
For the aged lady in the case study, the nurse must take proper care as the woman has heart
attack and her history also shows high blood pressure and osteoarthritis. High blood pressure

2CARE OF A PERSON WITH A MEDICAL CONDITION
leads to the heart attack so if the blood pressure of the lady is not controlled, then the heart attack
may occur again in future.
The three nursing assessments include admission assessment.The nurse must know properly
about the history of the old woman. Normally a nurse should know whether the patient has some
histories of allergies or reactions or medications, status of immunization and also the history of
the family. In the given case study. The patient has already found with the history of
osteoarthritis and high blood pressure. The nurse must know in detail about the medications that
she has already taken before ( Baket et al., 2013)
The patient’s physical, emotional and behaviour must be thoroughly considered by the nurse.
The emotions and behaviours of any patient changes with ages and so the nurses must also
possess accordingly. The care requirements of children are different from those of the adults and
adolescents. The children need care as given by the parents. The mood of the children also
changes because of the disease. The requirements of the adolescents are again different. The
maintaining of personal hygiene and proper communication is important. In the given case, the
patient is an aged woman who needs a care as a child gives to her mother. She needs all the
medicines to be given from time to time as it is difficult for an aged person to understand about
the medicines in details (Chen & Voyles, 2013).
The signs which are vital must also be considered by the nurse like temperature, blood
pressure, heart rate, pain, respiratory rate. Apart from these other requirements like height and
weight must also be considered. For the lady in the case study, the blood pressure has been found
to be very high which lead to her heart attack. She was also suffering from pain of arthritis. So
the nurse must proceed by considering the all conditions (Chen & Voyles, 2013).

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Shift assessment is another assessment. After completing each and every shift, the nurse has
the duty to complete the assessment of each and every patient. For the old lady, the nurse must
check the noises, cough and other secretions should be checked. The sound of the breathe,
movement of respiratory air and the requirements of oxygen must be checked regularly ( Ball et
al., 2014). The pulse rate, temperature of the body, colour of the skin, lip and nail bed is also
needed to be recorded. The old lady has been found to be a sufferer of osteoarthritis so she is no
doubt suffering from pain. The nurse must make sure that the pain is decreasing day by day. The
assessment of bowel and bladder systems should also be assessed (Sand‐Jecklin & Sherman,
2014).
Another important assessment is focussed assessment.This assessment involves assessing
in details the specific systems that the patient is affected. The woman of the case study needs the
following assessment:
Assessment of the respiratory system- The nurse must note about the duration of the cough if
it is present. Though respiratory problems are not reported in the history of the patient but still,
the respiratory rate should be checked, whether it is low or not. The shape of the chest should be
noted and also the tracheal position.
Assessment of circulatory system – The woman is suffering from heart attack, so this
assessment is the most important one as it measures the cardiac input and output. The status of
the circulation of blood and also the hydration status should be checked. The oedema condition
must also be checked by her. The rate of pulses and the skin conditions are also very important
( Leiberman et al., 2013).

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The diagnoses of the nurses is a part of the processes of nursing and also it is a judgement
which is done clinically regarding the individuality, community or family experiences to the
actual health problems and also the processes of life. The diagnoses of the nurses includes the
independent duties and interventions which are different when compared to those ordered by the
physicians. The diagnoses of the nurses are completely dependent on the data that are recorded
while doing the assessment. When a medical diagnosis identify a disorder, the nursing diagnoses
identify the problems which arises from the disorder. In the given case study, the nurse must do
the diagnoses of the old woman properly. The diagnoses that the nurse need to do are the actual
diagnoses. The actual diagnoses involves clinically judging everything about human experiences,
the responses of the family to the different health conditions and also the life processes that exist
within a person or within a family or within a community. In the case of this old woman, the
nurse must carefully do all these. The woman lives alone, she do not have any one. It is not
possible for the nurse to check her relatives but she can no doubt check the environment in which
she lives. The nurse can start doing the diagnoses as the history of disease of the patient is
already mentioned (de Araújo, de Carvalho & Chianca, 2014).
Another is risk diagnoses in this diagnoses recognises the responses of the humans to the
different health conditions or the life processes. This may lead to sometimes individuals who
become vulnerable. The increase in the vulnerability is meanly supported by the different risk
factors (Park, 2014).
In diagnosis of promotion of health the diagnoses involves a clinical journey which involves
the motivation of the patient, his family or a community regarding any diseases. This journey
desires to increase the wellbeing of people. It involves the human health potential which
enhances the behaviour of human health (Suarni, Nurjannah & Apriyani, 2015). The nurse must

5CARE OF A PERSON WITH A MEDICAL CONDITION
do every thing to provide awareness about the diseases to the old woman. The woman lives alone
and thus she do not have any one to look after. So the nurse has the soul duty to made the woman
understand about the diseases and wellbeing of human.
The present case scenario involves the case of heart failure. Proper education at the time of
discharge is very essential specially in the case of heart failure in order to improve the outcomes.
A team having multiple disciplines emphasizes on proper medication, restrictions on sodium and
fluids and recognizing different signs and symptoms that improve the progression of the disease
must provide patients and his family with healthcare benefits. Different pathways and different
structural tools of the hospital improves the conditions of the patients after discharge. The Patient
Management Tool is completely a web based interactive programme and it is also a reporting
system which do the tracking. This tool do the patient care by providing reminders of the
guidelines at the times of the requirements ( Warden et al., 2014). The tool also provide
reminders of the medicines specific to the diseases. The tool also gives a printed form of the
education specific education before the release of the patient. The patient also gets an automated
notes of dismissal and also the letter from the physicians (Black et al., 2014).
The team provides education to patients in order to increase the outcomes from the
patient. The patient in a hospital require regular visits by the nurses, the dietician and also the
general physicians from time to time ( Van Spall et al., 2017). The planning for the discharges
are made along with the nurses of the home made. In the given case study, the Miss Paterson was
a lonely person. She has no one to take care. So in this case, the hospital no doubt has to teach
her in all respect so that she never fails to take care of her alone at home. The multidisciplinary
team of the hospital will surely help the woman in giving release education.

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The members of the healthcare team who are involved in taking care of the patient are the
physician who is the leader of the healthcare team and he is responsible for all the decisions
about the treatment of the patients. He starts doing the treatment since the admission of the
patient till the discharge and also decides about the medications and surgeries.
Next are the residents, students of medical and the interns – In some hospitals the teaching of
the medical students are done. The residents are the licensed doctors who are involved in giving
the training of the students (You, Fowler & Heyland, 2014).
The specialist must be specialist for different diseases. For example, in the given case study
the woman is fund to suffer from heart diseases, so the cardiologists are the specialist which the
patient needs over here.
The nurse who are registered are the nurses who have the ability to provide medicines to the
patients and also to meet the physical needs and the emotional needs. Licensed practical nurses
are guided by the registered nurses and they are responsible for checking the blood pressure or
catheter inserting.
Patient advocate are responsible for listening all the complains about the healthcare services.
Technicians taking care of the patients, like those who take blood for tests, who help the patients
for walking (Gausvik et al., 2015).
The physical therapists who helps in treating the patients having walking problems or any
changing problem and the occupational therapists who help in the daily activities. Hospital
pharmacist help in aiding the patients with the medicines. The dieticians provide the patients
with proper diets according to their diseases they are suffering. The social services provide the

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services like support, education and information. Team who provide rapid response are the
hospital staff who takes the admission of the patient till the discharge of the patient. And other
radiologist and radiology technician who are involved in doing the tests of the patients (Scott et
al., 2013).

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