Use Of A Care Plan For The Patient And Her Specific Problems That Are Present At The Given Time

1411 WordsFeb 2, 20166 Pages
Introduction The purpose of this assignment is to illustrate the ability in a nursing context, to take information given on an assigned Case study scenario and carry out a complete documentation of a care plan for the patient and her specific problems that are present at the given time.. For the plan of care, I will look more in-depth at the scenario and case study provided for Mrs Greta Balodis, focusing on Day One post op care as requested for the documentation provided by the course co-ordinator. Assessing relevant care of Greta, with a view to the information from the case study. Using a full and complete care plan, the information will present in more detail two long term and two short-term key goals and the rationale of the…show more content…
old female, who has been admitted to hospital filling a fall fracturing the neck of the femur. Surgery for the issue was prior to the assessment piece, Greta gained admittance to the orthopaedics ward, and it is day one that the nursing care plan takes place. Greta’s past medical history includes a transient ischaemic attack in 2012, right-sided cerebral vascular accident in 2013, multiple falls, and atrial fibrillation. Since admission Greta has had a restless night with communication issues as Greta at times reverts to birth language of Latvian, her cognitive state has become more distressed and confused as the day has progressed and has showed signs of nausea. To assist in the making of goals for Greta, the model smart goals, Smart gaols were used to place a priority on goals and whether the goals would be obtain able or not. Making goals which cannot be obtained would be bad for the patients self – esteem, something which be suffering already due to multiple falls and the loss of her independence over the last few years. The first short term goal I chose would be getting the patients pain down to under 4, to recover and heal the body needs to rest and recuperate something it cannot do while in pain, to do this knowledge of medication that Greta is on , also take a part.. The second short term goal, was finding an effective communication style, to
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