Posted: April 13th, 2015

developing a plan of care for an adult

developing a plan of care for an adult

complete a plan of care. Once you have completed this form (yes you need to reference and include a reference list) I will upload the case study with the reading that you need to use and the plan of care form that you will use for this order. so you just need to do the work on the form not as an essay writing

•    Meet Simon

•    Personal details

Patient: Simon Jones
DOB: 15/3/53
Age: 60
Address: 56 Wattle Grove, McLaren Vale SA 5171
Weight: 85Kg
Height: 186.5cm
MRN: 835692
Family/Significant others
Partner: Jane Wills, 55 years old
Daughter: Ellen, 30 years old
Son: Adam, 27 years old
Hobbies
Fishing, hiking, camping and golf
Background
Mr Simon Jones is a 60 year-old man, who lives with his partner, Jane, in a single-storey home.  He is a retired Army Officer, who currently works as a book keeper in a family business.  He has one son and daughter from his first marriage. He has smoked 10 cigarettes per day for 30yrs (however, is currently in the process of reducing his intake).
Simon’s house has steps at the front and back, a walk-in shower and numerous rugs on the floors of the main living area.
Past medical history
Post Traumatic Stress Disorder (PTSD) secondary to Somalian Peace Keeper Tour with the Australian Army.
Past surgical history
“Occasional panadol for back pain.”
Past family history
No family history of bowel cancer.
Pre Diagnosis
Simon and his partner recently received via mail the “National Bowel screening kits” as they have recently turned 60 and 55 respectively.  They had also seen the National Bowel Cancer Screening Program TV advertisement while watching the nightly news bulletin.  Simon and Jane were surprised by how easy it was to complete the faecal test.
Jane remarked to Simon the day after the test “….I am not at all worried about the results… it is not as if any of us have a family member who has bowel cancer….”.
•    Day 1

•    The pathology RN visits Simon at 0800 and takes blood for a Full Blood Examination as per the Enhanced Recovery Pathway.
Simon is assisted to the shower by Warren the ward RN. Simon is a little unsteady on his feet when standing out of bed for the first time.
Simon’s perineal wound is washed under the shower, painted with betadine and kept clean and dry with pads and disposable pants after the shower.
He sits out of bed for a short time whilst Warren makes his bed. Warren provides Simon with a foam cushion for comfort when sitting as this will assist in relieving pressure from his perineal wound.
Simon returns back to bed after his shower as he feels “utterly exhausted…”.
Simon tolerates sitting out in a chair for lunch and later for dinner.
He tolerates a light breakfast and he is enjoying his supplemental drink twice a day. Simon’s IVT is ceased at lunch time as he is tolerating small amounts of diet and fluids however Simons FBC continues.
Warren explains to Simon that they will continue to measure his intake and output via his fluid balance chart with the plan to cease this tomorrow. Warren assessed Simon’s bowel sounds and found that they were audible. Jo the third year nursing student removes Simon’s IDC at 1000 under the supervision of Warren.
Simon is reviewed by the Acute Pain Service re his PCA with the plan to cease it tomorrow.  Simon continues to be administered O2 at 2l/min via nasal specs.
Simon is commenced on Low Molecular Heparin 5000units BD and this will continue for duration of his admission.
Simon’s observations continue 4/24.
Liz the STN reviews Simon mid-morning and examines his stoma and provides education around wound and stoma care.  Liz advises Simon that the abdominal wound Hydrocolloid dressing is to remain intact for at least 3 days.  Simon is a little unsure about attending to his stoma care today advising Liz that he is happy to watch her today. Liz applies a  drainable transparent ostomy bag and notes flatus and a loose bowel action from the stoma.
Jill the unit Physiotherapist reviews Simon mid-morning. She provides education around the importance of deep breathing and coughing exercises as well as teaching Simon with some simple bed exercises. Jill is pleased to see that Simon is using his triflow.
Jane and Ellen visit mid-morning and stay for lunch with Simon.
•    Day 2
Simon showers with assistance from student nurse Jo morning. Jo spends some time with Simon this morning chatting about his journey. Simon is most grateful to chat to Jo today as he was feeling quite “…overwhelmed with everything…”.   Jo talks to Veronica, the RN he is buddied with, and asks if he can take Simon outside in a wheel chair to spend some time in the patient garden. The trip outside to the garden brightens Simon’s day.
Simon is slowly mobilising with standby assistance around his bed space.  Simon tolerates sitting out of bed during the day today.
Simon is reviewed by Jill the unit Physiotherapist and Lauren the unit Occupational Therapist.
Liz reviews Simon in the afternoon and provides ongoing stoma care education.  Liz encourages Simon to remove any soiled ostomy bags and to begin cleaning his stoma and the surrounding skin with standby assistance from the ward nurses.  Liz also encourages Simon to start changing his ostomy bags during the day. Liz provides Simon with the Ostomy Association forms which Simon completes and Liz sends off for processing.
Simon’s midline wound covered with an Hydrocolloid dressing remains intact.
Simon’s perineal wound, continues to ooze.  Liz advises Simon to ensure he changes the pads regularly and after washing the wound, dab it dry.
Jo sits in on a discharge planning discussion that Veronica has with Simon, Jane, the unit Physiotherapist (PT) and Occupational Therapist (OT).
The Acute Pain Service review’s Simon and cease his PCA and commence him on PO Tramadol 50-100mg 4/24 prn.  Simon’s O2 is also ceased.
Simon is tolerating a light ward diet and he is enjoying his supplemental drink twice a day
Simon’s observations remain QID.
Day 3
Simon wakes early this morning as he has had trouble sleeping all night. Simon decides to shower early as he has had trouble sleeping all night and is awake early.  He showers with standby assistance from the night duty RN.
Simon is mobilising independently around his bed and walking the length of the ward with Jill the unit Physiotherapist. Simon continues to wear his Ted stockings and is independently completing his deep breathing and coughing exercises. Simon is managing to continuously raise all the balls in his Triflow.
Simon continues on QID Observations.
The STN, Liz visits Simon and his wound care/ stoma care lessons continue. Liz asks Simon if he is happy for her to invite Jane to tomorrow’s session.  Liz shows Simon a variety of closed bags that he may like to wear. Liz is pleased to see that Simon’s colostomy is functioning.

Simon is tolerating a light ward diet and he is enjoying his supplemental drink twice a day
Simon is administered the following medications as per his Medication Chart:
SC Heparin 5000 units BD
PO Ondansetron 4mg
PO Paracetamol 500mg ii 4/24 prn

eReading
Gulanick, M & Myers JL 2014, chapter 4 ‘Basic nursing concepts. Surgical experience: preoperative and postoperative care nursing care plans’, in Nursing care plans: diagnoses, interventions, and outcomes, 8th edn, Elsevier/Mosby, St Louis, pp. 235-250.
eReading
Swearingen, PL 2012, chapter 3 ‘Perioperative care’, in All-in-one care planning resource, 3rd edn, Elsevier/Mosby, Philadelphia, pp. 42-57
eReading
Gulanick, M & Myers JL 2014, ‘Post trauma syndrome’, in Nursing care plans: diagnoses, interventions, and outcomes, 8th edn, Elsevier/Mosby, St Louis, pp. 152-157.
eReading
Swearingen, PL 2012, chapter 5 ‘Psychosocial support’, in All-in-one care planning resource, 3rd edn, Elsevier/Mosby, Philadelphia, pp. 69-86.