Nursing Assessment Report: Patient Mrs. X, Long Term Care

This report details a comprehensive nursing assessment of an 88-year-old patient, Mrs. X, residing in a long-term care facility due to a cerebrovascular accident causing right-sided hemiplegia. The assessment utilizes Gordon's Functional Health Pattern framework, supplemented by the Hendrich II fall risk model and the Braden pressure ulcer risk assessment to identify patient needs and risks. The patient's health perception, nutrition, elimination, activity, sleep, cognitive function, and other patterns are evaluated. Focused assessments highlight the high risk of falls and pressure ulcers, leading to a care plan with specific interventions, including fall prevention strategies, pressure ulcer management, and nursing care strategies aligned with professional competencies. The report emphasizes the importance of maintaining skin integrity, promoting mobility, and ensuring patient safety within the context of the patient's physical and cognitive limitations. The interventions include keeping essential items within reach, using an alarm system, and providing physiotherapy to promote flexibility and endurance. The report also considers the patient's preferences, such as using Kawakawa Maori remedy for skin redness.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author note

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Introduction
The assignment is the outcome of the long term care placement. The assignment is the
assessment of the Mrs X an 88 year old patient currently residing in the long term care placement
due to left sided cerebrovascular accident which caused right sided hemiplegia. The elderly
patient will be evaluated using the “Gordon’s Functional Health pattern framework” (Gordon,
2016). The rationale for choosing this framework is the facility to conduct comprehensive
nursing assessment of the patient (Gordon, 2016). The patient data will be collected for focused
assessment using two evidence based tools. The first one is the Hendrich II fall risk model as the
hospitalized patient is at risk of fall (Campanini et al., 2018). The second tool is the Braden
pressure ulcer risk assessment, to determine the risk of pressure ulcer (Carreau et al., 2015). The
aim of the assessment is to prepare the care plan including interventions relevant to the clinical
condition of the patient. The care plan also includes nursing care strategies based on existing
literature. The compliance of the care plan to the registered nurses competencies especially
Domain 1 (1.2 and 1.5) as mentioned by the Nursing Council of New Zealand (2016) is
discussed.
The patient under care is the 88 year old lady admitted to hospital with right sided
hemiplegia caused by the cerebrovascular accident. She has the medical history of hypertension
that increases the risk of heart failure. She lives after her husband’s death with her children and
grandchildren. She has concerning issues with oedema lower extremities of her body such as her
right feet. She complains of limited dependence after hemiplegia and pain on rights side due to
strike. She has also concerns related to the deprived sleep, bladder and bowel continence. The
patient is however active, conscious and responds during interaction.

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Assessment
The following has been identified with Mrs X on completing the Gordon’s Functional
Health patterns framework assessment and compiled as below-
1. Health perception- Health Management
The patient demonstrated frustration due to limited dependence caused by hemiplegia.
She described her need for help with activities of daily living. She highlighted her medication
intake for sleep, bowel and blood pressure. Mrs admitted of her history of smoking and have quit
after stroke in 2016.
The patient demonstrates low pain tolerance as it is adding to her tress. She demonstrates
interest in gaining back her independence. The patient can well verbalise her concerns
Her current vital signs were noted as follows
 Respirations- 22 breaths
 Temperature: 36.8 degrees Celsius
 Blood Pressure- 140/90 maintained with Amlodipine (as it lowers high blood
pressure) (Fares et al., 2016)
 Oxygen Saturation- 98%
 Heart Rate- 81 beats per minute
 Weight - 92 kgs, Height: 175 cms- indicating BMI of 30.04, which means, the
patient is having obesity (Mandviwala, Khalid, & Deswal, 2016).
2. Nutrition-Metabolic pattern

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The patient takes rich diet and eats meals three times daily. She fails to adhere to the
dietary recommendations. She is recommended to have the puree diet. However, she
consumed the normal food taking care of the quantity and consistency of the food. She is
mindful of chewing food on left side of mouth. Mrs X feed herself and uses lower and
upper dentures and does not complain of difficulty in eating mashed food.
The usual food intake of patient is as follows-
1. Breakfast- Porridge with milk, with sugar toast, and one fruit. She takes high
calorie food evident from morning tea with hot chocolate, Biscuits, crackers or
pikelets with jam and cream
2. Lunch- Takes vegetables and chicken soup alternately, toast with spaghetti and
sausages and a fruit
3. Dinner- Toast with scramble eggs, and Steamed fish in sauce.
The patient has high intake of fluid as recommended by professional and is evident from
the water bottle beside her and pitcher of water and a cup within her reach.
The patient needs to reduce weight as she is obese and is risk factor for heart failure
(Mandviwala, Khalid & Deswal, 2016).
The skin condition that is pale colour and warm body indicates of low fever. The
pressure assessment was conducted for patient using the Braden’s scale and the score of 18
indicates high risk of ulcer (Carreau et al., 2015). The same is also evident from her inflamed and
red around groin, vulva and inner thighs. However, she prefers Kawakawa Maori remedy than
any other remedy.

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On further assessment nails/teeth/mucous membranes were all found to be intact and
healthy.
3. Elimination pattern
The patient complains of the bladder incontinence and requirement of the pads all the
time. She stated having constipation and need of laxative that is laxsol for easy emptying
of bowels (Every-Palmer, et al., 2017).
She described her bowel motion to occur once in a day in afternoon between 2:30-4:00
and describes her stool as solid, medium and deep brown in colour. She has concerning
issues with oedema lower extremities of her body. She wakes at night to urinate.
4. Activity- Exercise pattern
The patient initially independent and after hemiplegia her dependence has increased. She
can mobilise with wheel chair but needs help with activities of daily living. on fall risk
assessment using the Hendrich II falls risk model, a score of 8 was found putting her at
high risk of fall. In the get up and go test there was inability to rise without assistance
(Campanini et al., 2018).
5. Sleep- Rest pattern
Mrs complained of lack of stable sleep pattern, and high pain. She needs splint at night to
prevent foot drop and pain medication.
6. Cognitive- Perceptual pattern

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There are not many significant issues with speech, voice, or memory as she can
remember names. She requires glasses for reading and hearing is intact for her age
7. Self- Perceptual- Self-Concept pattern
The patient is family oriented and identifies herself as a mother, teacher, wife,
grandmother, friend, social worker, teacher, and a JP. She prefers to comb her hair herself
indicating high self care and groom. She also demonstrates independence using unaffected hand
as much possible. She cannot walk and takes help for hygiene and transfers.
8. Role- Relationship pattern
She loves to be in company of her family and loves to enjoy weekends and holidays with
friends. She herself advocates as her son has EPA.
9. Sexuality- Reproductive pattern
The patient is widow but stated to be happily married for 60 years. She had no regrets
with her marriage and enjoys being with her two sons , five grandchildren and her
professional life.
10. Coping- Stress tolerance pattern
She is able to cop because of family strength. Other stress coping strategies includes
reading and playing bingo
11. Value- Belief pattern
The patient admires education and states her practicing religion as Anglican. Mrs X
believes in respecting elders and treating them with respect and dignity.

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Focused assessment
The two concerning issues as per the above assessment are the risk of fall due to
hemiplegia, and pressure ulcer. For the first issue the Hendrich II fall risk model assessment was
completed. This model gives information of the risk factor associated with the patients with a
certain score (Campanini et al., 2018). As per the data collected the patient did score for altered
elimination, and for taking antiepileptic that is Gabapentin and for taking Temazepam a
benzodiazepines. Gabapentin is useful to treat seizure and shingles (Lu et al., 2017). Temazepam
is used to treat trouble causing unstable sleep (Schweitzer & Feren, 2017).). Based on the get-up-
and-go-test, it was found that the patient scored for unable to rise without assistance during test.
This test highlights the patient’s ability to independently sit or lay in bed. Therefore, the total
score sums up to 8 putting her at high risk of fall (Campanini et al., 2018). The patient is a high
risk patient as she is completely dependent on staff for transfers. Therefore, the nursing
implication in this case is to develop fall prevention strategies as a part of the care plan. In this
situation, the nursing goal is to decrease the fall risk factor and related injuries. Therefore the
nursing interventions are targeted for improving mobility issues and promote beneficence
(Manda-Taylor, Mndolo & Baker, 2017). To ensure safety the patient may have her belongings
close by her side and alarm system to notify her attempt to wake up (Health Quality and Safety
Commission New Zealand, 2017). The same will be discussed in subsequent sections in details.
The next issue to be highlighted was pressure ulcer and it was confirmed by completing
the Braden pressure ulcer risk assessment model. It helps assess the patient’s mobility, degree of
physical activity which is risk factors for pressure ulcer (Trepanier & Hilsenbeck, 2014). Her
score in details is as follows –

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1. Sensory perception of pressure related discomfort- 3 indicating slightly limited
response to verbal commands with slight hearing loss. Lack of feeling of pain
may be one or two extremities
2. Degree of skin exposure to moisture- 3 indicating Mrs X skin is occasionally
moist may when changing the linen or wiping face with towel
3. Degree of physical activity- 2 indicating chair fast that is restricted to electronic
wheel chair as the patient cannot bear her own weight
4. Mobility that is ability to change body positions- 2 indicated very limited
mobility. It highlights the difficulty making significant changes independently.
5. Usual food and nutrition pattern-3 indicating intake of complete meal while
meeting nutritional requirements
6. Friction and shear- 1 indicating problem where moderate assistance is required
The score sums up to 14 indicating high risk of pressure ulcer (Carreau et al., 2015). Te
score implies nurses to take actions for preventing the pressure ulcer such as measures to
maintain skin integrity maintain fluid balance chart or encourage patient report pain (Cooper,
2013). It will be discussed in details in subsequent sections.
Interventions
The nursing interventions for reducing the fall risk in patient are keeping the necessary
items in the easy reach, such as telephone, urinal, water, as keeping gem too far may cause
hazard and fall. The patient will be provided with alarm system to prevent patient going out of
bed without any assistance. It is the top priority amongst patients with a high fall risk scores
(Morse, Merry & Bloswick, 2016). The patient’s bed will placed in lowest position for easy

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transfer to wheel chair. The patient’s room will be ensured with adequate lightening to increase
visibility at night time wake up (Trepanier & Hilsenbeck, 2014). The patient will be advocated
to use hearing aid as it promotes health as well reduce hazard by increasing the auditory
orientation to the environment. It will reduce the impact of falls; and minimize risk of falls or
injuries. The patient will be assisted with physiotherapy. The physiotherapist may be consulted
to develop detailed plan for strengthening and conditions. It will help develop flexibility and
endurance (Karinkanta et al., 2010). These evidence based interventions promote a safe, stress-
free environment for the patient, knowing her personal items are within reach when required
(Health Quality and Safety Commission New Zealand, 2017, p. 3).
The package of care for Mrs X to reduce the risk of pressure ulcer includes medium
package (Raju et al., 2015). The nursing care strategies for this condition involves daily
monitoring of the full skin integrity and documentation of the same for tracking the changes as
impairment becomes prominent with thinning of epidermis (Cooper, 2013). The patient may be
repositioned on bed frequently to prevent ulcer and sores. The patient will be educated to do
frequent small shifts of the body weight. Further, it will be ensured that the patient’s bed linen is
clean dry and wrinkle free, as moisture increases skin maceration. The patient will be provided
with her preferred Kawakawa Maori remedy for redness of skin to protect skin for excoriation. It
is the traditional healing method of New Zealand. This remedy is known for antiviral and anti-
inflammatory properties (Aichele, 2016). Since the client has elimination problem there will be
appropriate adherence to the food chart and fluid balance recommendations. The input and
output will be monitored to prevent infection. The incontinence pads will be frequently checked
and the same will be instructed to Mrs X. It is because urine turns into ammonia and is erosive to
skin (Thompson, 2017). As the patient has slight intolerance to pain she will be instructed to

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report pain over bony prominences as it is the area of high risk for tissue ischemia. Also
prophylactic pain medication may be an issue (Black et al., 2010).
Overall the assessment conducted and the care plan was designed in the manner that it
complied with the competencies for registered nurses, Nursing Council of New Zealand (2016).
During nursing care, it will be ensured that the patient is respected (means whakaaute in tikanga
practice) as she older adult and believes in treating elders with respect and dignity. This practice
is in alignment with cultural safety principle as per treaty of Waitangi. The Domain 1,
competency 1.2 was met by protecting the patient’s dignity and respect during hygiene practices
and assisting for mobility. Further, the patient was given her preferred Kawakawa Maori remedy
for redness of skin. It will help patient determine as being culturally safe. It indicates meeting
the competency 1.5 of Domain 1 in the Competencies for registered nurses, Nursing Council of
New Zealand (2016). Therefore, the nursing care demonstrated the professional responsibility of
respecting the patent’s identity, personal beliefs, goals and values.

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