Based on the scenario above, please use the general survey process to describe the areas that you would be observing immediately upon entry to the home.
Since the patient (Millie Gardner) is reported to be old, my first observation will be to assess and confirm the appearance of the patient in relation to the reported age. Secondly, I would check her facial expressions for any signs of acute distress as well as the body structure of the patient, for example, the range of body weight, height and nutritional status (Jarvis, 2016). Moreover, since the patient is confined to a wheelchair I will check her comfortability while sited. Lastly, I would also check on the fitness and cleanliness of the patient and also that of their rambunctious miniature Doberman pinscher dog.
What, if any, concerns related to Millie’s skin and nutritional status do you have?
What nursing interventions will you include in the plan of care to address these concerns?
In order to address the above concerns about pressure ulcers, the nursing intervention I would include in the care plan will be regular change Millie’s sitting position and also recommend use of cushions as well as personally designed mattresses to protect body parts that are vulnerable to pressure ulcers. I would also suggest the use of gels and creams on the affected areas so as to help in relieving pressure and healing process. I will also include in the care plan a dietary eating plan which comprises of a diet rich in fruits and vegetables.
What teaching strategies will you use to educate Millie and Fred on the new medications?
Using SBAR, please include the information that you will communicate to the physician’s office at the completion of the visit.
The information will include: the situation is that Millie has been discharged from a medical surgical unit where she had been admitted for 9-days. The background information is that she is 83 years old with a history of pneumonia, dehydration, hypertension, type II diabetes and also cerebral vascular accident. The assessment indicates that the patient is at risk of developing pressure ulcers due to prolonged sitting times on the wheelchair. I, therefore, recommend that her sitting position be change regularly and also a nurse to make weekly visits to her home to assess her situation.
References
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.
Langley-Evans, S., & King, C. (2014). Assessment of nutritional status in clinical settings. Journal of Human Nutrition and Dietetics, 27(2), 105-106.
