Care Plan Based on Activities of Daily Living Model

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Part A This portfolio entry requires an assessment and care plan to be presented incorporating the nursing process based on a client that I assisted in the care of during my clinical placement. The patient on which the care plan will be assessed will be a 72 year old female, May Watters who I assisted in the care of during clinical placement in the Emergency Department (ED). May Watters is a pseudo name to ensure confidentiality to An Bord Analtrais standards (ABA 2000). May was brought in by ambulance which was called by her husband Jimmy. May was brought into the ED for Diarrhoea and Vomiting 5/7 days and generally unwell and weakness and non productive cough. Mays’ husband who is her next of kin was concerned about her deterioration…show more content…
However, in reading the literature and partaking in Mays care it is noted that that the care required is complex requiring planning of many AL’s; the main priorities including; breathing, controlling body temperature, eating and drinking, and eliminating. These are based on assessment, medical diagnosis, nursing diagnosis and how May feels about her health in general. Breathing is the priority that I will be addressing and “...must be considered of prime importance because it essential for all other activities” (Roper et al 1996). In Mays case the main problems identified in the nursing assessment were shortness of breath (SOB), cyanosis and a non productive cough. Because of the complexity of illnesses of the respiratory system and the potential systemic effects if not managed appropriately the initial assessment was very important. Part of the assessment is to document any history of chronic lung problems which in Mays case is diagnosed asthma and any medications she is taking for this. The purpose of the assessment is to discover the individuals’ normal breathing habits and comparing to the physical reality of the situation. This assessment also included taking a smoking history to plan for smoking cessation if the patient wished to do so which at the time she did not, and to evaluate Mays psychological condition as anxiety can have a huge biological effect on breathing (Roper et al 2001, Holland et al 2003) Dyspnoea is considered a
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