Nursing case study and care plan development

Nursing Case and Care Plan

William Smith is a 68-year-old man who was transferred to the Palliative Care ward from a surgical ward three days ago. The patient was admitted on January 26, 2013 for removal of a sacral abscess that had been a source of a lot of pain to him. Following his surgery, his future management was evaluated and it was decided that he would be transferred to the Palliative Care ward since he could not be discharged home. The palliative assessment of Smith would require the development of a suitable nursing care plan that would help deal with the condition. The nursing plan requires an understanding of the patient's social history, medical history, physical assessment upon admission, and palliative care unit admission assessment.

Nursing Case

Could Mr. Smith's culture influence his pain assessment? Why? What strategies could you employ to ensure that you are adequately addressing Mr. Smith's pain?

Mr. Smith is an indigenous Australian i.e. An individual of Aboriginal or Torres Strait Islander descent. As an indigenous Australian, Mr. Smith culture has influenced his pain assessment given the role of culture in healthcare. Actually, it is evident that there is a variation between non-indigenous and indigenous Australians in terms of interpretation of death and dying as well as other aspects of health and well-being (Queensland Health, 2011). Mr. Smith's culture influences his pain assessment because of the variance in customary practices between indigenous Australians and non-indigenous Australians. In essence, health and well-being is interpreted differently among this people, especially hospital admission, which is viewed as a place an individual goes to die.

Therefore, it is important to develop and implement appropriate strategies to ensure that Mr. Smith's pain is adequately addressed. This process entails consideration of the impact of geographical and cultural aspects on individuals and communities and barriers in order to obtain a detailed view of the health and well-being of indigenous Australians. One of the strategies to ensure that Mr. Smith's pain is adequately addressed is to deal with personal and/or spiritual issues. This is primarily because Aboriginal and Torres Strait Islander people tend to consider factors that are associated with ill health such as pain and discomfort as personal or spiritual issues (Commonwealth of Australian, 2005). This implies that dealing with pain would require dealing with personal or spiritual issues as well as cultural transgression since it influences Mr. Smith's perception of pain. Secondly, I would ensure Mr. Smith discusses certain issues with a health worker or social worker to promote understanding of the current situation and illness. Third, measures will be established to address Mr. Smith's current family situation as part of enhancing his social and emotional well-being and deal with the pain.

2. Consider Mr. Smith's social and medical history.

a. Reflect on any judgements and prejudices that you may have when caring for Mr. Smith.

Mr. Smith's social and medical history may generate some prejudices and judgments when caring for him and addressing his condition. One of the judgment is that is a violent and stubborn individual since he has a past history of domestic violence and abuse. Secondly, he does not want consider hospital admission as a place for healing and well-being but for death since many indigenous people view health facilities as places of death. Third, it is difficult to deal with him since he refuses any home help despite being unable to care for himself. Fourth, his condition could have partly been brought by his history of alcohol abuse and heavy smoking.

b. Review the following professional Australian nursing standards: Code of Ethics for Nurses, Code of Professional Conduct for Nurses, EN Competency Standards. Outline the standards / codes that relate to non-judgemental nursing care in this situation.

There are various standards or codes in the Australian health sector that relate to non-judgemental nursing care in Mr. Smith's situation. The relevant codes in this situation include value statement 1 to value statement 7 in the Code of Ethics for Nurses in Australia. Secondly, Conduct Statement 1to Conduct Statement 10 in the Code of Professional Conduct for Nurses in Australia are standards that relate to non-judgemental nursing care in Mr. Smith's condition. The other standards that relate to this situation are competence units in EN competency standards that govern nursing practice.

3. Compile a list of questions you would ask Mr. Smith as part of a holistic health assessment. These questions should be framed to enable collection of information on:

A. Physical health status including pain assessment

i. How would you rate your daily energy levels?

ii. Do you experience any headaches, joint aches, and muscle pain?

iii. How would you describe your ability to exercise?

iv. How would you rate your overall physical health?

v. Describe for me your pain.

B. Mental and emotional status

i. What is your sense or perception of well-being? Do you think you measure to those standards?

ii. How would you rate your overall mental health?

iv. What is the level of your self-esteem and self acceptance?

v. How much are you capable of working with others in a meaningful way?

vi. How often to you experience difficulties with stress, negativity, anger, emotional numbness, boredom, and depression?

C. Social and cultural issues

i. How would you rate your closest relationships as well as interactions with friends and acquaintances?

ii. Do you actively devote time for your spiritual well-being?

iii. What is your perception of hospital admission?

iv. How has your experience of pain altered your social life?

v. Has your experience of pain altered your sense of belonging to a community or group?

4. Mr. Smith asks you about planning for his future. He states that he does not want to be resuscitated. Provide Mr. Smith with a brief description of the following and apply it to this scenario:

a. Advanced Health Directive: This is a formal method of providing instructions for an individual's future health care and is enforced when the person is unable to make his/her own decisions (Public Guardian, n.d.). In this case, Mr. Smith will provide information regarding his special health conditions, spiritual and cultural values that could affect his care, and any allergies to medications.

b. Enduring Power of Attorney: A legal agreement that permits an individual to appoint a trusted person or people to make property or financial decisions (Queensland Government, 2013). For Mr. Smith, an enduring power of attorney would be ideal since he may unable to make decisions when necessary, especially those related to medical treatment due to his illness.

c. Organ Donation: It is the process of giving your organs for transplant, especially to someone with damaged organs that may require replacement (Kidney Health Australia, 2014). Mr. Smith may consider donating his organs in order to save someone's life or considerably enhance their quality of life and health.

5: Suggest alternative strategies (complimentary therapies) other than pharmaceutical pain management that could help Mr. Smith's pain.

Apart from pharmaceutical pain management, Mr. Smith's condition can be addresses through alternative strategies or complimentary therapies. Some of the relevant complimentary therapies for Mr. Smith's pain include spiritual healing, dietary supplements, massage, meditation or relaxation, reflexology, and cognitive behavioral therapy (Care Search, 2009).

6. List appropriate referrals for Mr. Smith to other members of the multi-disciplinary team. Provide a rationale and a description of the service for each referral.

Mr. Smith's situation may require the use of a multidisciplinary team through which different professionals with varying, complementary skills work together to provide comprehensive health care. The use of a multidisciplinary team would be appropriate in this situation to provide the best optimal outcome for the patient's physical and psychosocial needs. One of the referrals for Mr. Smith is a general practitioner who is a health professional operating in diverse clinical areas. A general practitioner would be appropriate in this situation because of experience in addressing chronic conditions and pain management. Secondly, Mr. Smith would benefit from support groups who work in collaboration with the physician in assisting the patient to manage pain. Support groups would be ideal to ensure that the needs and concerns of the patient in relation pain are highlighted and ensure the patient is better equipped and well informed to make decisions when necessary. The third referral is a physical therapist or physiotherapist who helps in handling physical pain. This professional would be relevant in Mr. Smith's case because he/she will help in developing a treatment recovery plan. A rehabilitation doctor is also an important referral since he/she utilizes behavioral therapy to help in enhancing quality of life and health through restoring physical activities.

7. What support / referral could be offered to Mr. Smith's family?

The support or referral that could be offered to Mr. Smith's family is a patient support group that would not only provide support to the patient but also encourage and advice the family in relation to the patient's pain management.

8. Outline the pathophysiology of the following conditions ensuring you relate back to Mr. Smith and his clinical presentation. Include within your answer the possible management strategies and rationale for these symptoms:

a. Anorexia: The body processes that contribute to this condition include personality disorders, eating disorders, anxiety disorders, and mood disorders. These conditions are evident in Mr. Smith's condition because of his addiction to alcohol and heavy smoking, troubled relationships with family members, and refusal to eat. Some of the probable management strategies include nutritional rehabilitation, behavioral therapy, psychosocial interventions, and medications.

b. Ascites: This is brought by cirrhosis of the liver and fluid retention in the abdominal cavity, which may be evident in Mr. Smith's situation due to the past history of alcohol abuse and smoking. Probable management strategies include relaxation, drug abuse rehabilitation, and medications.

c. Dyspnoea: Intense sensations, burden of daily living activities, and extreme distress are the main contributors to this condition. For Mr. Smith, dyspnoea may be brought by distress about his current situation and troubled family relationships. The management strategies include blood tests, physical therapy interventions, exercise training, and oxygen therapy.

d. Hiccups: Mr. Smith has complained of hiccups which is caused by intercostal muscle contraction and instantly followed by laryngeal closure. The probable management strategies include drug treatment and breathe holding and folk therapies.

9. Consider Mr. Smith's deterioration. What data provided about Mr. Smith's condition on 06/02/2013 would assist in determining if Mr. Smith is at end of life?

The data that would help in determining if Mr. Smith is at end of life include increased breathlessness, increased need for assistance with personal hygiene, poor coordination since he can be confused and agitated sometimes, depression, and plans for a visit with his children.

PART B: Nursing Plan

After spending a week in the Palliative Care ward, Mr. Smith's condition deteriorated to an extent that he is currently bed bound. The deterioration has been characterized by increased need for help with personal hygiene, extreme sensitivity to soap, increased breathlessness, occasional confusion and agitation, and refusal to wear his dentures because of severe pain in his mouth. This condition requires the development of a nursing plan that would effectively address Mr. Smith's condition and improve his health and quality of life.

The first part of a nursing care plan for Mr. Smith is a physical assessment based on the medical record and activities of daily living. Based on his medical record, it seems that Mr. Smith has reached an end of life period that is characterized by deterioration of his condition. Mr. Smith is having difficulties with physical movement and activity since he requires help with personal hygiene, has mouth ulcers that are extremely painful, and has poor eating habits to an extent that he is ordered soft diet, encourage fluids. The condition has had considerable effects on his activities of daily living because of difficulties in coordination, mobility, and physical activity or exercise. He spends most of the day on the hospital bed with limited mobility and increased breathlessness. The only physical activity that he is able to undertake is rolling from side to side for palliative care. His difficulties in coordination are evident in the occasional confusion and agitation he exhibits. Mr. Smith's rate of daily energy intake has also continued to worsen since admission in the Palliative Care ward. Even though, he rarely complains of any headaches, muscle pain, and joint pains, Mr. Smith seems to have difficulties in body movement and does not exercise.

It is increasingly evident that the patient requires end of life care since he displays signs and symptoms of end of life. Generally, the most common signs and symptoms of end of life include nausea, constipation, and shortness of breath though these symptoms vary for every individual (National Cancer Institute, n.d.). Constipation is evident in Mr. Smith's since BNO is administered for several days and microlax enema and aragol 10ml given with effect. The other signs and symptoms of end of life in the patient include loss of appetite, excessive fatigue and sleep, increased physical weakness, mental confusion and disorientation, changes in urination, and depression about his current state.