Patient's Case Study: Nursing Problems and Goals

Consider the Patient

Mr. Jones, an 86-year-old male who was recently widowed, was brought to the hospital by ambulance after being found wandering up and down his street by the neighbor. It was revealed that Mr. Jones was limping, favoring his left shin, with physical examination confirms the presence of blood stains on his pants and socks. He also has a skin tear on his left leg. According to Mr. Jones, he fell over, something which he cannot remember vividly. He was ordered to remain on a bed rest while waiting for x-rays to confirm whether or not he sustained fractures from the fall. Mr. Jones has been complaining of pain in the left hip and leg where he has a wound (laceration from the fall). Further interactions with the patient revealed that he has not been eating well since his wife passed away two months ago. He mainly eats frozen meals or takes away meals. He stays at home and is reluctant to go out as he feels sad most of the time. Later in the day, Mr. Joness X-ray shows no fractures. His pain score has remained at 7/10, and he is becoming confused and agitated

Collect cues/Information

Mr. Jones observations include:

Blood Pressure: BP 165/95 mmHg

Temperature: T 37.9C

Heart rate: P 105 bpm

Respiratory: R 24 breathes per minute

Height: He is 177 cm tall

Weight: He weighs 125kgs

Pain Score: 7/10; location: left hip and leg

STAR Skin Tear Classification System: Category 3 skin tear

High falls risk; Score 17

Waterlow score 16.

CS 14 with normal power in the right leg, mild weakness in left leg, pupils equal and reacting (sluggish)

Bowels not open for 2 days (BNO x Day 2)

Mr. Jones Prescription:

Irbesarten 150mg PO Daily

Paracetamol 1gm PRN 6/24

Metformin 1000mg PO Daily

Salbutamol metered dose inhaler 1-2 puffs every 4-6 hours

Symbicort Turbuhaler 160/4.5mcg 2 inhalations BD

Mr. Jones Co-Morbidities

Hypertension

Type 2 Diabetes

Asthma

Arthritis

Process information

Mr. Jones has a high blood pressure of BP 165/95 mmHg. The high systolic pressure and diastolic pressure indicates that Mr. Jones has a health problem with his body fluids (blood) which needs to be rectified to salvage his situation. It is also revealed that his body temperature is T37.9C which is an indication that he has a slight fever since the normal body temperature for older people ought to be averagely, T37.0C. The patient has a higher respiration rate of 24 breathes per minute. This can be attributed to the patients fever and pain resulting from the wounds/injuries sustained after falling. The higher respiration rate can also be linked to Mr. Jones advancing age, who is now 86-year-old. Mr. Jones heart rates is P 105 bpm, which is on the high side.

The high heart rate led to examination of the patient whether or not he was feeling, dizzy and breathing complication. Apparently, Mr. Jones was also suffering from shortness of breath as attested by higher respiratory rate of 24 breathes per minute. The high blood pressure and a respiration rate on the high side could be as the result of psychological trauma the patient is undergoing after the loss of his wife. The patient lives alone in a single storey house with to steps at the entrance. It is apparent that he has not recovered from the demise of his wife. This implies that Mr. Jones needs a continuing care during this transitional period. The patients waterlow score is 16 suggesting that he is at a high risk of developing pressure ulcer.

According to the pain scale, Mr. Jones has the pain score of 7/10, which indicates that he is experiencing severe pains. He also has a skin tear to his left shin. According to Mr. Jones, he fell over, something which he cannot remember vivi6dly. The x-rays depicts that Mr. Jones did not have a fracture after falling: however, his pain score remains to be severe (7/10). The patients physical examination indicates that he has a Category 3 skin tear, which attests that he suffered from the skin tear with a complete tissue loss. The patient demonstrates CS 14 with normal power in the right leg, mild weakness in left leg, pupils equal and reacting (sluggish).

Mr. Jones is also enduring psychological pain. He is 86-years old and recently lost his wife. It is apparent that death of his wife has hit him hard, prompting him to wander up and down in the street. Further interactions with Mr. Jones reveals that he has not been eating well since his wife passed away two months ago. He claims that he mainly eats frozen meals or take away meals. He stays at home and is reluctant to go out as he feels sad most of the time. These are the symptoms of an individual who is experiencing psychological trauma. The patients comorbidities are hypertension, type 2 diabetes, asthma, and arthritis. He is also vulnerable to depression.

Identify problems/issues

What is the issue for the patient?

Establish Goals

What do you want to do here for the patient Take Action

What will you do here in the way of care for the patient? Rationalise your nursing action

Why have you chosen the actions you want to do for the patient?

First Nursing Problem

High blood pressure is one is one of the nursing problem. Upon his arrival in the hospital, Mr. Jones physical examination reveals that he has a BP of 165/95 mmHg; Heart rate: P 105 bpm and Respiratory: R 24 breathes per minute. His hypertension is worsening and he needs immediate medication to salvage his condition. The patients water low score of 16, which implies that he is a high risk of pressure ulcer, is the sign that Mr. Jones hypertension problem is becoming critical.

One Nursing Goal

I want to improve the patients hemodynamic status. Apparently, Mr. Jones has a high blood pressure of BP 165/95 mmHg. This situation is putting him at increased risks of chronic conditions such as hypertension, which is likely to occur as the result of the cardiovascular changes in his body system. I am supposed to take the patients blood pressure to the normal levels, which will involve the use of particular prescription and medication. The focus will also be on easing the patients slight fever as well as rectifying his heart rates and respiratory rates which are on high side. The clinical activities will be performed with an objective of solving the patients deteriorating cardiovascular system, as depicted through hypertension symptoms

First action

After establishing that Mr. Jones hypertensive condition was worsening, I embarked on performing nursing interventions with the aim of easing his situation. This involved reviewing of the risks such increased vascular resistance and vasoconstriction. I focused on the activities that can decrease the patients BP or cardiac workload. The intervention actions included the monitoring and recording of the BP for a patient, to obtain the comparison of pressures, which is vital for the provision of a vivid picture of vascular involvement. I also evaluated the clients reports regarding extreme fatigue and his intolerances for activities.

The desired outcomes for these activities included maintenance of the patients blood pressure within the acceptable range. The treatment is also expected to demonstrate an acceptable and stable cardiac rhythm and rates that deemed standard, within the normal range of the patient. Rationale

Reviewing of the risks associated with the hypertensive condition will be crucial when it comes to preventing the compromising of blood circulation which can place increased demands on the heart. This will also help in the identification of the factors contributing to Mr. Jones high blood pressure. Through the comparison of the patients BP against the normal BP ranges, it is possible to get a clear picture of the scope of the problem. Implementation of the activity restrictions will play a significant role in reducing physical stress and tension that can be adverse to his blood pressure.

Second action

Maintaining activity restrictions (bed rest) is also another nursing action that will be implemented as part of the diagnosis for Mr. Jones high blood pressure condition. I will also instruct the patient to observe relaxations techniques and distractions that can help him reduce the stressful stimuli. Finally, I will monitor the patients response to medications provided to control blood pressure and fever.

The desired outcomes will also target on helping Mr. Jones participate in the activities which will ultimately reduce his vulnerability to stress and depression.

Rationale

The provision of comfort measures will lessen the discomforts felt by the patient thus decreasing sympathetic stimulation. Furthermore, the relaxation techniques applied will facilitate the reduction of the stressful stimuli thus producing a calming effect which is vital in lowering the patients BP. Monitoring of the clients responses to medications meant to alleviate the threat of hypertension will be useful in assessing the drug therapy.

Second Nursing Problem

Stress and anxiety is also another nursing problem identified in the case of Mr. Jones. He is brought in the hospital after being found loitering in the street. The patient is 86-year-old, who recently became a widow. Mr. Jones stays alone in a single storey house, with two steps. He is finding it hard to deal with loss of is wife. He asserts that his appetite has deteriorated, hence limiting his diet to frozen meals or take away meals. He stays at home and is reluctant to go out as he feels sad most of the time, which are critical symptoms of person suffering depression. He also has a Category 3 skin tear after sustaining injuries from a fall. He is complaining of pain in the left hip and leg where he has a wound, with his pain score remaining to be severe (7/10).

One Nursing Goal

Addressing the patients stress and anxiety is also another goal for the identified nursing problems. Before brought to the hospital, Mr. Jones is found wandering in the street. His physical examination reveals that he has a wound in the left hip (laceration from the fall). His pain score is high, and he is at increased risk of developing the pressure ulcer. Evaluation of the patients status reveals that Mr. Jones is suffering from psychological trauma (geriatric depression). The treatment plan will target on providing continuity nursing care for the patient, who is in a transition phase after becoming a widower, recently. This will involve solving his anger and appetite problems. The patient is also lonely. At his advanced age, it is not appropriate for him to stay alone in a single storey house with two steps at the entrance. It is imperative to consider taking the patient to the home nursing care First action

Evaluation of Mr. Jones psychological state indicates that he is enduring stress and anxiety (geriatric depression) which might have been prompted by the death of his wife. I will initiate various gross motor activities such as walking that will ensure Mr. Jones apply little concentration. The activities will be one-to-one since he is most depressed. This will make sure that the patient optimizes the significance of interactions while at the same time minimizing stress and anxiety levels. The interactions will also be vital in reducing loneliness that has beleaguered Mr. Jones since the passing on of his wife. Later on, I will consider involving Mr. Jones in group activities such as group discussions and dance therapy. This will help him to shift his minds from things that are stressing him (stressors).

Rationale

Individuals who are battling with stress and anxiety typically concentration and have memory problems (Hoffman, 2007). Involvement in the gross motor activities will help Mr. Jones to relieve tension, ultimately helping in elevation of his moods. Participating in one-to-one activities ensure that the patient utilizes the potential of interactions which reduces the anxiety levels. Sociali...