Health Assessment & Nursing Care Plan- Kevin Jones Case Study- Paralysis

NURBN 2009: Health Assessment & Nursing Care Plan- Kevin Jones Case Study- Paralysis- Nursing Assignment Help

Task:

You are required to complete a comprehensive health assessment and nursing care plan on information given to you in the case study- Mr. Kevin Jones.

To demonstrate your developing skills required to produce a comprehensive nursing health assessment by the clinical decision making process, identification /assessment of nursing problems (nursing diagnosis), planning and implementation of nursing care, documentation of nursing data and evaluation of nursing care.Students are required to discuss in 2000 words the physical and mental health components for the assessment case study.

1. This needs to be written according to academic standards and conventions.
2. Students will be required toidentify4 major issuesof the case study and write a summary of your overall assessment of this person.
3. Ensure that ‘objective’ language is used. This would be similar to what is written in nursing notes as an admission history.
4. Using the Nursing diagnosis section of the Adult health assessment booklet, identify and list as many nursing diagnosis as may relate to the Case study and provide the evidence from assessment that supports this.
5. Now prioritise the3 most important nursing problems (diagnoses)to formulate a nursing care plan. As the overall goal is discharge planning, consider this in formulating the nursing care plan and related interventions.
6. Develop a nursing care plan with rationale and related interventions that could be implemented for Kevin (Case Study) .
7. Be sure to identify ways that you could measure success in relation to each of these Interventions – complete the evaluation sections of the care plan.
8. This assessment requires you to develop a critical assessment of the relevant information surrounding the case study.

Case Study – Mr Kevin Jones

Mr Kevin Jones is a 75 year old gentleman who is under your care. He has been widowed for 13 yearsand has recently suffered a stroke. He lives alone in a rural location and was a farmer during hisworking life.

Kevin has 3 grown up children, two of whom live outside of Victoria and his middle son livesnearby but leads a busy working and family life. He does not get along too well with his daughter in law. Kevinis fiercely independent and during hishospitalisation has verbalised his wish to return to his home and manage on his own, against the wishes ofhis family.

Finances are limited. He lives in anold farm house which hasn’t seen renovations for 30 years. He has a wood fire and stove and noshower (just a bath).

Past history: Prostate Enlargement, Hypertension, Alcoholism, Depression and Anxiety

Currently Kevin has right side paralysis due to his CVA (stroke). Kevin does not appear to notice that he leans to one sideand forgets where his right hand may be. His speech is slurred and he has trouble saying some words. This causeshim some frustration and he has emotional outbursts at times.He has just started to mobilisewith a three pronged stick and he is anxious about his balance.

Kevin is anxious about returning home and seems to be fretting about his home, land and animals (currently being taken care of by one of his sons). Some days, Kevin barely talks to the staff and will often get agitated and irritable with the nurses, physiotherapists, cleaners etc. He appears to be ruminiating about his past and his wife.

Kevin has been complaining of a chronic cough with a small amount of discoloured greenish yellow sputum, fever,flushed skin, chills, loss of appetite, taking little fluids, malaise and body aches over the past few days. Temp 38.3, BP – 90/60, Resp rate – 24/ min, P 90 , O2 sats – 93%. Crackles & wheezes on auscultation, diminished breath sounds.

Chest X-Ray revealed (R) lower lobe pnuemonia.

Kevin also has someswallowing difficulties and some vision problems with neglect. When he does eat, he prefers puree and soft style deserts e.g. custard. He is not drinking much. Kevin appears to have lost weight. His skin turgor is dry, mucous membranes dry, urine specific gravity is 1.025, decreased urinary output, increased urine concentration and he has an elevated blood urea nitrogen.

He is finding that he is more likely todribble following passing urine and sometimes he is incontinent of urine. His bowels are a little erraticand his stool has been hard and dry lately. Lately, this is causing him considerable distress.

 

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