You are the nurse allocated to provide nursing care for Mr. Z. He is admitted to your ward following a fall at home earlier this morning where he fractured his R) Neck of Femur. Mr. Z. is scheduled for theater tomorrow morning.
As a nurse, you are required to understand and manage the problems that patients are at high risk of experiencing following a fall at home. You must be able to anticipate any other serious issues that may occur and plan for how you would manage these problems.
You are required to apply a person-centered care approach using the CLINICAL REASONING CYCLE (see Appendix Two) to prioritize care for the next eight hours, that is pre-operatively.
The patient data required for the assignment may be found at the end of this document in the appendix.
Assignment guidelines & structure:
Using the principles of patient-centered care and the CLINICAL REASONING CYCLE, develop a nursing management plan for the eight hours following Mr. Z’s admission to the ward, pre-operatively.
1. Using the clinical reasoning cycle, list at least three (3) actual or potential nursing problem statements in order of priority.
Each of these nursing problem statements must be supported by the cues and data from the scenario and justified (referenced) using current nursing literature. Nursing problem statements should be 3 part statements e.g. Problems related to etiology (cause) as evidenced by signs & symptoms. Nursing problem statements are not one-word statements like “Pain”
2. Select the highest priority statement (Choose only one (1)).
For the Nursing Problem Statement, you must:
1. Explain why it is of high priority to make use of evidence from the literature.
2. Formulate patient-centered goals for your care. Remember that nursing care goals must be specific, measurable, achievable, and realistic and have a time-frame (SMART criteria).
3. Identify three (3) relevant nursing interventions that you would implement to meet the patient-centered goal listed above. Discuss each intervention and rationale using evidence from the current peer-reviewed nursing literature.
List the evidence-based assessment criteria that you would use to evaluate Mr. Z’s response to your care.
Patient Name: Mr. Z
Social: Mr. Z is an 84 yr old man who lives alone. His wife of 60 years passed away recently and his son lives in Australia. Mr. Z’s neighbor found her lying on the floor of his apartment this morning when she went to visit.
Past history: Mr. Z has a history of hypercholesterolemia, hypertension, and congestive cardiac failure. He has recently become a little forgetful but maintains an active lifestyle, going for a daily walk with his neighbor.
Allergies: Nil Known
On Admission Assessment:
Alert & oriented, PEARLA
c/o moderate pain R) hip with obvious bruising to his R) hip, R) arm and face
He has a dressing to his R) forehead where he received 8 stitches for a significant laceration from his fall.
BP 142/88, HR 110, T 373.
Chest clear, SpO2 97% RA, AE equal to bases.
Height 164 cm, weight 75 Kg
BGL 5.6 mmol/L
HNPU since admission