Nursing

Brief overview of the situation – this would include the relevant assessment data you have from the case study.

Bill is 88 years old retired farmer who moved from his farm about three years ago. He has been living with Alzheimer's type dementia for about six years. His only other medical diagnoses are peripheral neuropathy which is secondary to type 2 diabetes mellitus. He lives with his 86 year old wife Jane. They moved from their two story farm house to a small home in town about three miles away. Their son now farms the land that his parents moved from.

Both Jane and Bill made it clear to their physician that they want to continue to live in their new home in town for as long as possible. They have advanced directives in place and have made it clear that they want to remain comfortable, but do not want any life prolonging measures implemented. Their financial resources are not a significant concern this time.

What data do you need to collect to develop a care plan that would facilitate optimal outcomes? Based on the assessment data you already have, choose a minimum of three evidence-based assessment tools to gather relevant data. Then what data did you collect using these tools? Note: this data will be fictitious. Be specific, remembering that a care plan is only as good as the data it is based on.

When I ask Jane what she is most concerned about, she replies quickly. According to Jane, her husband falls about twice a month without serious injury. He has a history of pressure wounds on the lateral aspects of both feet. Jane said it is 'terrible' when Bill has wounds on his feet. She reports that he is more confused, falls more, the wound dressings are very challenging for her. She adds that when Bill can't get his boots on to go to the farm, he gets agitated. Jane says she is 'getting tired' and has been feeling more stressed lately.

Bill takes metformin daily, but no other medications. Bill has lost ten pounds in the last three months and has a BMI of 22. Jane receives an injection for osteoporosis twice a year and uses eye drops for glaucoma. She describes her physical health as very good, she just gets tired.

Focused physical assessment of Bill: BP: 140/86; apical pulse: 84 and regular; lung sounds clear; +1 edema of feet and ankles. Skin intact with reddened areas on lateral aspects of both feet at this time.

Scarring from prior foot wounds noted bilaterally. Most recent labs from clinic visit two weeks ago: Hgl A1C is 6.9; Hgl 12.0; prealbumin 15 mg/dL.

Because of the falls, I would assess orthostatic hypotension, gait, balance, mobility, and the environment. Due to his history of pressure wounds and the peripheral neuropathy, I would assess skin integrity and his nutrition more carefully.

I will include Jane in the interview. When I ask about sleep, Jane says Bill is usually up very early, but sleeps well from 9pm - 4am. Jane usually sleeps fairly well, but wakes up worrying about what their future holds.

Jane reports that Bill is incontinent of urine about three times a week and wears pull ups. She tries to remember to guide him to the bathroom every couple of hours and limits his fluids after 4pm. Bowel function is OK.

Jane tells you Bill never complains about pain. He had a knee replacement ten years ago and Jane remembers the nurses commented on the fact that Bill never admitted to any pain.

Jane shares that Bill is becoming more and more confused. He continues to recognize her and their son on the farm, but not many other people. She shares that if they go out to the farm for a couple of hours every afternoon, Bill is more content the rest of the day.

Jane shares that Bill uses the bathroom independently as long as she reminds him on time, that he dresses himself (but needs her to tell him how to do that), he is content to have Jane drive to the farm, and his mobility is ok, except that he falls regularly.

Bill feeds himself but prefers mostly sweets. Jane tells you this is a change over the last years as he used to eat a lot of meat.

Based on the overview and focused assessment and history, three evidence based assessment tools that would be valuable include:

Braden Scale for Predicting Pressure Sore Risk.

· John does not respond to a prick with a filament distal to his knees. John scores 3 for sensory perception. You also notice that John has mild edema in both feet and that his shoes are tight and challenging to get on and off.

· John wears briefs to manage what his wife describes as 'rare' urinary incontinence. His wife helps with changing when wet - she estimates about three times a week. John scores 4 for moisture.

· John is able to ambulate around their small home freely. He also wanders out of doors about three times a week. John scores 4 for activity.

· John is able to make changes in body position independently. He scores a 4 for mobility

· John's nutrition is probably inadequate. Jane tells you he rarely eats a complete meal. His favorite foods are sweets and desserts He doesn't consume many fluids – he tells you "then I have to go to the

bathroom". John scores 2 for nutrition. He does tell you that he does like chocolate ensure once in a while.

* Friction and shear are a potential problem for John. He slides to the edge of his chair to get out of it. John scores a 2 for friction and shear. You also noted very significant friction on his heel when trying to put his shoes back on. When he sits in his recliner, he rests his heels on the footrest.

Total Braden score is 19 indicating he is at low risk for skin breakdown. This score is likely falsely reassuring. Risk for wounds on his feet remains a significant area of concern due to his history, the mild edema in his feet, and his limited sensory perception in his feet. When I assessed his feet there is evidence of healed wounds on lateral aspects of both feet. Upon questioning, Bill states he thinks he "needs new farm boots". Jane agrees that Bill's boots are challenging to get on, and often moist inside.

I would also consider doing a fall risk assessment (due to the recent falls), a Caregiver Strain assessment on Jane (due to her statements indicating she is 'getting tired' and has been feeling more stressed lately).

Note this highlighted section is not part of the example: There are more assessment tools that could be valuable in this situation (ex, KATZ Index of Activities of Daily Living; a nutritional status assessment; a depression scale, a social isolation scale, a PAINAD scale, and more). Remember that

assessment is ongoing and for this fictitious care plan, I want to see you prioritizing. For this assignment chose two evidence based assessment tools that you determine are priorities.

Based on your assessment data, what are three priority nursing concerns? Justify your prioritization. You can write these as nursing diagnoses, or as priority concerns. One will be a physical concern; one a psychosocial concern; and the third can be either physical or psychosocial.

Then, formulate a measurable goal for EACH priority concern. Then, formulate at least one evidence-based intervention to help meet that goal. How might you evaluate?

Priority concern # 1: Risk for pressure wounds

Justification of prioritization: When I asked Jane and Bill what they were most concerned about, Jane immediately talked about the past wounds on Bill's feet. Even though Bill's Braden score is good, when considering the whole situation this is a serious risk due to the history of prior wounds, edema, wearing 'farm boots', and the dementia. In Bill's situation, another wound (and the possibility of surgery or even amputation) would likely contribute to increased confusion, contribute to more falls, limit John's mobility (at least for a while), and increase stress for both John and his wife. It would likely lead to increased caregiving demands and physical strain for his wife and potentially require a move from their home for at least a time.

Goal: John's skin will remain intact through the next four weeks .

Interventions:

1) Teach Will and especially Jane about the importance of appropriate shoes and boots (although it is likely that Will may not recall the teaching, he will be included). Assist with securing shoes and boots that Will would wear and that are easy to put on and off. (citation)

2) Instruct both Will and Jane regarding foot care for diabetics (again, (although it is likely that Will may not recall the teaching, he will be included). Leave written instructions. Ask for a teach back.

3) Encourage protein rich foods that Will likes - such as the chocolate ensure and other protein rich foods that they can afford and Jane can easily prepare.

4) Encourage Will to elevate his feet when in his recliner to reduce some edema.

How will the nurse evaluate?

Inspect Will's skin and especially his feet will be intact at each nursing visit over the next month. If intact, continue with current plan. If not intact, reassess and develop additional / different interventions.

Priority concern # 2

Justification of prioritization:

Goal:

Interventions:

How will the nurse evaluate?

Priority concerns # 3

Justification of prioritization:

Goal:

Interventions:

How will the nurse evaluate?

How will you promote patient and family centered care? How will you ensure that the patient and family are involved in developing goals and interventions?

I asked Jane and Will what is most important to them at this point in time. Jane was most concerned about wounds, the falls, and her own ability to 'hold up' and continue to care for Will in their home. After the goals were established related to wounds, falls, and her caregiver stress, I asked what they were willing and able to do to meet those goals.

Jane shares that Bill is determined to go to the farm every day that the weather is decent to 'look around.' Jane states Bill is fine with Jane driving, and she enjoys these visits to the farm as well as she typically has a chance to visit with her son. Although there is increased risk for falling and foot wounds since Bill wears the 'farm boots', this is what they want to do. Jane says she feels much better after 'getting out', and also that Will is more content after he has been to the farm. Jane's driver's license is good for two more years, her physical health is good, and she tells you that she drives out during the time of day she knows traffic is minimal.

I encouraged Jane and Bill to do most of the talking during the first visit while I actively listened. I will check frequently for understanding of the information and had Jane do a teach back regarding foot care and fall risk.

Include more examples of individual/family involvement

Consideration of rural residence. A minimum of two concepts of Rural Nursing Theory are examined as they apply in this situation.

The concept of self-reliance is likely important in this scenario. Jane tells you that they are both proud of working hard, caring for and raising their family on the farm. It will be important to respect their autonomy and ability to care for themselves as much as possible (elaborate more on this).

Will need to examine a second concept from Rural Nursing Theory. Those concepts were introduced during week one of the course and are introduced on p. 6 of the text edited by Winters

Concluding statements: