Question

Case Study

Mrs. A.K. is a 101-year-old woman who resides on LL at Rossland Terrraces Long-term Care Home. She has been a resident of LL since 2016 after suffering a fall in her apartment. She is wheelchair bound and is a mechanical lift for transfer. She enjoys participating in the social activities offered by the home. She eats independently, but requires assistance for other activities of daily living. Her son often visits her.

Health conditions: hypertension, dementia

Diet: as tolerated, regular diet, no dysphagia (feeds herself)

Neuro – alert, orientated to person

CVS – afebrile, warm, well-perfused BP 140/60, HR 75, capillary refill less than 3 seconds, good peripheral pulses (2+)

RESP – breathing comfortably on room air. No work of breathing, RR18, SpO₂ 95%, lungs clear, decreased air entry to the bases.

GI – regular diet, wears dentures

GU – requires assistance for toileting

INT – skin thin, old skin tear noted on right arm, redness in the coccyx area. Denies pain to the coccyx.

MSK – mechanical lift for transfers and wheelchair bound, previous knee surgery bilaterally

1. Identify 2 needs that are priorities in the care plan of a resident of LTC and provide rationale for making these needs priorities. For each of the needs, develop a written plan of care that reflects the collaborative nature of goal-setting and care planning. Refer to Potter & Perry chapter re Planning and Implementing Care to review the Nursing Process.

2. Nursing Care Plan Template          

Initials:________ Significant Medical Diagnoses: ______________________________  

Safety Considerations: ____________________________________________________

Activity level and restrictions: ______________________________________________

Activities of Daily Living: __________________________________________________   

Assessment of issue (NANDA Nursing Diagnosis): ____________________________________________________________________

Assessment Data	Planning or Client Outcomes	Nursing Interventions or Plan	Rationale for Interventions	Evaluation or result of the intervention
Issue of exploration (What is the problem or potential problem?): Subjective data: Objective data:	Short term by the end of shift: SMART Longer term:

Answer 1

Initials : Mrs aks

Significant medical diagnosis: hypertension, dementia

Safety consideration: bound to a wheelchair

Activity level and restrictions: immobilize

Activities of daily living: need assistance except for eating

Assessment data

subjective data: suffering a fall in the apartment , denies pain to coccyx region

Objective data: thin skin, old tear noted on rt arm , redness in coccyx region , BP : 140/60, HR : 75b/min ,

RR: 18, SPO2 ; 95%

PLANNING OR CLIENT OUTCOME

Short term : Avoid prolonged sitting , , can use coccygeal cushion to ease pressure on coccyx region

nursiong intervention : relive the area from contact and also promote blood supply and faster healing of the area

Long term: physiotherapy, positioning laterally in bed  

Nursing interventions; promote the strengthening of the tissues and can overcome the issuse

Rationale For Interventions

1) the redness seen in the coccyx region may also have hurt the internal structure , if so can perevent further injury

2) In long term the planning can improve the healing of the region faster