Nursing assesment and its role in care planning Essay

Nursing assesment and its role in care planning - Essay Example ing alarm/rescue, and frequency/pattern of falls; assessment include emergency care fundamentals such as airway, breathing, circulation, disability, and exposure; locomotor problems include physiological effects of aging; loss refers to reduced or loss of vision; and social circumstances include history of social circumstances, support network people, and type of housing or social contact (Jones, Endacott & Crouch 2003, p. 82). Applying the assessment tool, the nurse has gathered the following assessment data: Patient X fell on the ground at 5:00 pm. She has been lying still on the ground for 3 hours in her house until help is sought by a concerned neighbor. Assessment of fall history revealed a misplaced placemat on the floor as a hazard for the occurrence of fall. The patient only regained consciousness when she’s in the hospital and clearly recollects incident of fall and other previous experiences. Patient X has no method of raising alarm/rescue and there were no other fre quency/pattern of falls except for the current incident. Nursing assessment revealed a patent airway and a regular breathing pattern (20 breaths /minute). Circulatory perfusion is assessed using the neurovascular examination and found a 3 seconds toe capillary time which indicate that the circulation in the lower extremity are starting to be compromised (Brunner et al. 2009, p. 2100). Neurological assessment described Patient X as lethargic upon admission and GCS scores totaled to 12 because of lapses in verbal responses due to confusion and disorientation and withdrawal of motor responses when pain is experienced. A full physical assessment were done presenting fall impact on the lateral aspect of the hip, pain the groin with radiation to the knee, pain exacerbated by movement, and inability to... The paper tells that fractured neck of the femur is more common among older people and women and affected individuals are likely to experience significant distress, physical pain, complications, and possible incapacitation. The acronym FALLS served as assessment guidelines for older people who have fallen. FALLS stands for falls history, assessment, locomotor problems, loss, and social circumstances. The Hendrich II Fall Risk Model is used in assessing the degree of risk of falls among elderly population whereas the In Ottawa knee rules identifies the need for further investigation, imaging, or X-ray. The case scenario of Patient X identified nursing care needs in peripheral circulation, safe discharge, and independent rehabilitation. To improve tissue perfusion in peripheral areas, nurses need to: perform patient assessment and monitoring which includes ABCs, C-spine and hemorrhage control to aid the nurse in discovering overt/covert changes in patient’s status at frequent i ntervals; perform neurological exam such as Glasgow Coma Scale and note vital signs at frequent intervals to early recognize changes and to provide timely and appropriate care; and perform capillary refill checks and assessment of neurovascular function of the immobilized extremity to determine status of tissue perfusion. Discharge plans follow as tissue perfusion is resolved. An effective discharge plan follows the Department of Health’s key principles in discharge planning and is holistic, promote active and equal partnership, well-coordinated, and maximized to the full potential.