Practical Nursing Program – Client’s Nursing Care Plan Assessment Answer

Data Analysis and Interpretation

Nursing Diagnosis 

(Client’s issues)

Objectives

Nursing Interventions and justifications

Evaluation

(Indicate date and evaluation of the objective)

96-year-old female with delirium, as well as confusion, and has a history of unwitnessed fall.

Delirium and Confusion

1. Improve cognitive function and reduce confusion. 2. Prevent further falls and injuries.

The primary goal here is to improve cognitive function and reduce confusion in the patient.

Nursing Interventions and Justifications: For the sake of accomplishing this objective, a multifaceted approach is necessary. Implementing a cognitive intervention, such as reality orientation, providing familiar objects, and offering positive feedback is the way to focus upon.

- Reality Orientation: This involves gently reminding the patient of essential information such as her name, location, and date. Displaying a clock and calendar in her room to help her maintain a connection with reality should also be executed. This is crucial for someone with dementia, as it can reduce anxiety and confusion.

- Familiar Objects: The presence of familiar objects should be encouraged, such as family photos or her favorite items, to create a comforting environment. Familiar items can help ground the patient and provide a sense of continuity. Inculcating familiar objects would inherently assist the patient to recollect and recapitulate in a seamless manner, regarding her past experiences to mitigate any sort of confusion and ameliorate her cognitive functionalities in a similar vein.

- Positive Feedback: The contribution of positive feedback in terms of propelling encouragement and positive reinforcement, when the patient expresses coherent thoughts or behaviors is essential is undeniable in nature. Owing to the fact that positive feedback has the potency of enhancing self esteem. At the outset it also motivates her to frequently engage in appropriate behavior and helps to maintain a positive therapeutic relationship.

Fall prevention is crucial for a patient who has already experienced an unwitnessed fall.

- Bed and Chair Alarms: Inculcating chair alarms as well as alarm beside bedside would assist the nursing staff to be alerted and able to deliver prompt response, whenever the patient attempts to get up without support or assistance. According to a recent study conducted by the University of North Carolina in 2016, it is revealed that approximately 18% of fall prevention cases can be mitigated right of the chart, if adequate measures such as bed and chair alarms are incorporated in due time. These alarms serve as early-warning systems and help prevent falls. Audible alarms can also remind the patient not to get up alone.

- Education on Fall Prevention: Apparently it would seem that education on fall prevention is not a sincere concept. However, in reality, it is a crucial component that should be concentrated upon. In view of the fact that educating the patient as well as her brother regarding the gravity of fall prevention would ensure that assertive measures are taken into regard for safeguarding the ambience. Aside from that incorporation of assistive devices that are adequate enough for the sake of ensuring fall prevention should be carried out respectively.

Evaluation: Regular assessments will be conducted to evaluate the patient's cognitive function and confusion levels. Over time, it is expected to notice a reduction in confusion and improved cognitive function. Progress will be tracked to adjust interventions as needed.

Ongoing assessments will determine the effectiveness of bed and chair alarms in preventing falls. A lack of fall-related injuries or incidents will indicate success in achieving this objective.

Osteoporosis, Atrial Fibrillation, Dementia, and Hypertension.

Osteoporosis, Atrial Fibrillation, Dementia, Hypertension

1. Manage chronic conditions effectively. 2. Prevent complications related to these conditions.

The objective is to manage the patient's chronic conditions effectively and prevent complications.

Nursing Interventions and Justifications: Managing osteoporosis, atrial fibrillation, dementia, and hypertension requires a comprehensive approach.

- Assessment and Education: The prudential action course in this instance is to intricately analyze the risk of patient pertaining to the conditions and substantiate necessary education coherent with each condition. This falls under the continuum ranging from elaborating the gravity of prescribed medication to ensuring that the patient understands the significance of lifestyle modifications and takes necessary measures accordingly.  

- Blood Pressure Monitoring: Keeping a track of blood pressure on a regular basis is instrumental in the context of managing hypertension. Followed by collaborating with healthcare professionals in order to evaluate current landscape of the patient, for the sake of augmenting a care plan that is individualized and able to deliver holistic care seamlessly.

Success in managing these conditions will be revealed if vital signs turn out to be stable, adherence to medications and lifestyle modifications, and the absence of complications related to these conditions.

Incontinence, inability to eat solid foods, and aspiration risk.

Incontinence, Dysphagia, Aspiration Risk

1. Manage incontinence is the primary objective. 2. Ensuring the patient's nutritional needs are met without aspiration.

The objectives are to manage incontinence and ensure the patient's nutritional needs are met without aspiration.

Nursing Interventions and Justifications: Incontinence and the patient's difficulty in eating solid foods pose unique challenges.

- Incontinence Care: In the realm of incontinence care, the comfort of the patient as well as hygiene pertaining to the patient should be prioritized immensely. If prompt actions are taken, including changing briefs as needed, then the feasibility of experiencing wellbeing seamlessly and swiftly would be inevitable.

- Nutrition Management: In the context of managing the patient’s inability to consume solid food particles and her risk of aspiration, a puree diet would be introduced, which is beneficial for the patient from nutritional perspective as well as convenient for her to digest it. Besides educating the benefit of upright eating and ensuring that the process is maintained by providing a pillow for optimal positioning, inculcation of suction equipment will be readily available to manage any aspiration risk.

Successful management will be evident when the patient remains continent and receives proper nutrition without aspiration or related complications.

Lack of family support and memory difficulties.

Support System, Memory Difficulties

1. Substantiating an emotional support and furnishing open flow of communication with family members should be facilitated. 2. Another objective is to facilitate memory support.

The patient's support system and memory difficulties require a personalized approach.

- Family Engagement: It is imperative to engage who is the family member of the patient specifically the patient's brother, whose contribution is unequivocal in her support system and establish ongoing channels of communication through which additional information can be substantiated whenever needed. From an apparent vision this would only seem like an extra precaution, but in reality, this substantiates as an emotional support all while furnishing a sense of security which is quintessential for the patient to experience mental well-being. 

- Memory Support: the background of the patient should be equated as a teacher to stimulate her memory and cognitive function. In this manner, the next course of action is to engage in this course with the patient and encourage conversation pertinent to her teaching experiences, thereby providing necessary positive stimuli for memory retention. The reason being that often it is experienced in the course of practice, that recapitulating past experience assist an individual experiencing through mental impediments rejuvenate her well-being within a short span of time.

Evaluation: Successful achievement of these objectives will be reflected in the patient's emotional well-being, improved memory with assistance, and enhanced communication with her support system.

Satisfaction with care but occasional agitation.

Satisfaction with Care, Agitation

The objective is maintaining patient satisfaction as well as mitigating the notion of agitation completely.

One of the crucial aspects that should be taken into consideration after intricately analyzing the overall case study is that as far as providing holistic care is concerned, it is imperative to understand and evaluate the preferences of the patient, so that the quality of care can be tailored accordingly. Due to previous history of anxiety and confusion is pertinent in this instance, prior to implementing a strategy it should be taken into consideration that inculcating new changes in daily regime would inherently be experienced by challenges. Hence, mitigating the notion of anxiety as well as confusion is prudential in this instance.

As far the assessment is concerned, if the patient consistently expressed satisfaction regarding the new regime and experiences alleviation of mental upliftment, then the feasibility of equating it with stress reduction as well as reducing agitation is feasible.