Nursing For Foundations of Care

Introduction to Edward’s Care Plan

In old patients, it is often observed that they face a few common problems such as nutrition-related issues or hypertension with age. If appropriate care is not delivered then risks for serious complications may increase. A patient who suffered a fall is often assessed with tools such as pain score tool, FRAT, and others. Effective nursing care helps in continued and improved care will be ensured. However, in the case of old patients, a patient-centered care plan should be developed with patient involvement so that self-management is encouraged. In this essay, the following sections will discuss the risk assessments, nursing diagnosis priority, plan of care, nursing intervention, and evaluation for the case study.

Case Study Outline

It is a case study of an 80-year-old patient named Edward Essex who fell in the bathroom while assisting his wife. His pain score is 2/10, vital signs such as temperature, blood pressure, heart rate, and others are normal. He had a medical history of hypertension, hypercholesterolemia, gastro-oesophageal-reflux-disease, arthritis, atrial fibrillation, and permanent face-maker. He can walk independently and his cognitive functions are all intact and have lost 3 kgs in the past 6 months and he is allergic to fish and aspirin as well.

Risk Assessment

As per the Fall Risk Assessment Tool (FRAT), it is clear from the case study that Edward had no fall since the fast 12 months, no medication for sedatives or hypertension, experiences no psychological issues, and the cognitive status is also normal. All these factors showed that the patient showed a score of 5/20 with low fall risks (health.vic, 2020). As per the BRADEN risk assessment tool, it is clear from the case study that Edward had sensory perception completely intact, the skin is moist, walks frequently, face no limitation to mobility, nutrition is appropriate, and there is no friction or sheer as he can walk independently; showing a score of 21with low-pressure sore risk (Healthcare Improvement Scotland, 2020). As per the Mini Nutritional Assessment (MNA) tool, it is clear from the case study that Edward showed no decrease in food intake, 3 kg weight loss, no psychological stress, and no neuropsychological problems with a score of 10 and this shows that Edward is at risk of malnutrition (Nestle Nutrition Institute, 2020). As the risk of malnutrition is present so, the health professionals should actively take actions for the patient’s safety, the patient or his family members should be informed about the health issues for increasing the partnership, and continued care should be delivered such as preparing a plan of care (Australian Commission on Safety and Quality in Health Care, 2020). It is often found that with aging the risk of malnutrition increases and functional decline, therefore, the screening should be effective for ensuring improved patient outcomes.

Nursing Diagnosis

The highest nursing diagnosis priority is malnutrition, followed by diagnosis for gastro-oesophageal-reflux-disease (GORD) because Edward had a history of the same and then diagnosis for hypertension because his wife does not outsiders inside the house, this might result in stress or feelings of loneliness in the patient that might result in hypertension. The patient already had a history of hypertension so there are chances that he might be diagnosed with it by the nursing care. According to Craven et al. (2016), the patients who are at risk of malnutrition should be diagnosed for their body mass index, weight, and diet patterns. The patient should be diagnosed for satiety immediately upon ingesting food, insufficient muscle tone, insufficient interest in food, bowel movements sounds, and weight loss. It is often found that older patients due to misinformation or misconceptions suffer from the risks of malnutrition and poor health. From the case study, it is found that Edward takes medication for GOR disease and medical history for it. So, the medical staff should prioritize it for diagnosis. According to Poledníková et al. (2019) & Dirac et al. (2020), gastro-oesophageal reflux disease s very common in old patients and the old patients often do not show symptoms such as acid regurgitation or heartburn therefore, it can lead to serious complications if left untreated and undiagnosed. If left undiagnosed can lead to gastric ulcers, dental erosion, oesophageal inflammation, and perforations. Moreover, it is often found that the old patient feels lonely and stressed if there is no communication with friends or family members. This result in stressful conditions and can lead to high blood pressure causing hypertension (Ferreira et al., 2020). In this case, it is found that Edward does not talk to friends or other neighbors and he is socially less interactive due to the behavior of his wife and had a medical history for the same as well. It is observed that patients with hypertension suffer from falls or are at risk of falls therefore it is a priority for the medical staff to diagnose the patient for the same (Ferreira et al., 2020).

Plan of Care

The issues of malnutrition, GORD, and hypertension should be resolved with SMART goals so that patient does not suffer from serious complications at the later stages. According to Devault (2017) & Volkert et al. (2019), depression, social isolation, and other factors are found to impact the nutritional status of the individual. The old patient care plan should aim to improve the nutritional status to meet the energy needs, he should be recommended for physical examinations or sessions should be prescribed by the physicians or nutritionists. Health literacy is very important to ensure positive health outcomes and it is often found that the old patients require face-to-face interaction, repetition of the same points again and again to remember it. The patient should be educated about his health issue and asked to self-monitor his eating patterns and weight. He should be provided with a nurse visit for home medical care services for continued services so that he does have to travel to the hospital in his old age. According to Chait (2010), the old patient with GORD should be recommended for endoscopic examination with appropriate cautions, he should be asked to observe the symptoms of chest burn, the patient should be asked to elevate the level of his bed to resolve the issue to some extent, he should be asked to reposition himself with the aim to maintain an airway and prevent aspiration. The GORD patient should be asked to quit smoking, alcohol, and use antacids. Few medications for GORD in the elderly cause dizziness, nausea, and confusion, so they should be avoided. According to Acelajado (2010), a patient with hypertensive issues should be asked to monitor his blood pressure regularly, take appropriate levels of sodium and potassium in his diet. High blood pressure is also associated with various other cardiovascular issues in old age, therefore, cardiovascular health should be assessed. The patient should be encouraged for physical activities and reduce stress by meeting friends.

Nursing Interventions

According to Ten Cate et al. (2020), it is found that physical examination of grip strength test and pitting edema is a sign of malnutrition. The nursing intervention for malnutrition is the nurse should determine the time when the hunger of the patient is at peak. It is often found that old patients are found to have a high appetite during morning time that might be associated with risks of liver issues. The patients with liver issues have high hunger for breakfast. The patient should be asked not to make carbonated drinks and the nurse should recommend a liquid diet that is easy to digest for old patients. According to Commisso et al. (2019), for treatment of GORD, the patients should be given with proton-pump inhibitors and antidiarrhoeal medicines and the nurse should recommend to gastroenterologists and general practitioners. The nurse should educate the patients to eat slowly and masticate the food properly. There should be gastrointestinal endoscopy so monitor the tissue damage. As per the nursing standards of a registered nurse, there should be effective communication (standard 2) with the old patient as they more time to understand the remember the information, and physical examination should be appropriately conducted as per standard 4 of comprehensive assessment conduction. The nurse should monitor the outcomes of the patents (standard 7) and if unexpected outcomes have resulted then alternate care should be developed (standard 5) (Nursing and Midwifery Board of Australia, 2020). According to Oh et al. (2017), for hypertensive patients the nursing interventions include prescriptions of the dietician for a healthy diet with fruits and vegetables, anti-hypertensive drugs, monitoring of the serum sodium and potassium levels to ensure supervision of the blood pressure, the nurse should also monitor the rate of heartbeats, pulse, and rhythm. The patient should be asked for his knowledge about the health condition so that complete information can be transferred to the patient for appropriate care.

Evaluation of Edward’s Care Plan

If the patient does not successfully perform the grip strength test then it helps in evaluating that there is poor muscle strength in the old patient, indicating the risk of malnutrition. If the patient shows edema on the extremities then the nurse can evaluate that he has malnutrition but if appropriate nursing care is delivered and all the tests and examination turns out to be passed successfully by the patient with no weight loss and feels energetic as his nutritional diet meets all his energy requirement then the risk to fall or other nutrition-related issues will be resolved with positive patient outcomes (Ten Cate et al., 2020). The score tolls such as FRAT, MNA, and BRADEN should be used again to record the score after the care delivery to evaluate the patient outcomes. If the scores indicate low risk or no risks for each category then it will indicate that the results for positive health outcomes are maintained. An assessment of the skin, hair, and nail can help the nurse to evaluate the nutritional status of the patient, such as a patient's appropriate nutritional status exhibits moist skin, and no signs of scaly or dry skin. The positive patient outcomes for GORD can be evaluated by maintaining a record for the patient’s experiences of symptoms of chest burn or acidity. If medications and diet are appropriately followed then the patient will record no signs of chest burn, no gastric tissue damage will be documented during examinations, with proper repositioning the airway will be well oriented, the patient will have no regurgitation of acids in the oesophagus, no irritability or stomach ache (Chait, 2020). Evaluation of the mucosal layer of the oesophagus helps in the evaluation of the GORD and if there is no damage to the layer then it means the patient has improved. There will be no records of consistent weight loss if there are positive health outcomes in the case of a patient with GORD (Commisso et al., 2019). By monitoring the records of the blood pressure can help in evaluating the hypertension issues. The blood pressure should be maintained at 120/80 and feedback from the patient about his social interaction will help the nurse to evaluate his psychological states that will positively impact his stressful feelings. A positive result if cardiovascular functions ensure a healthy patient with normal blood pressure (Acelajado, 2010).

Conclusion on Edward’s Care Plan

It is concluded that Edward is at the risk of malnutrition and he should be provided with appropriate nursing care for the health issue. He should be educated about his disease and appropriate physical tests and examinations should be conducted for him so that a care plan can be developed. He should be provided with liquid diet, antacids should meet with friends to get rid of stressful feelings if any, and should be asked to monitor his blood pressure daily. He should avoid smoking and alcohol to maintain a healthy gastric state.

References for Edward’s Care Plan

Acelajado M. C. (2010). Optimal management of hypertension in elderly patients. Integrated Blood Pressure Control3, 145–153. https://doi.org/10.2147/IBPC.S6778

Australian Commission on Safety and Quality in Health Care. (2020). Australian safety and quality framework for health care. Retrieved from: https://www.safetyandquality.gov.au/sites/default/files/migrated/32296-Australian-SandQ-Framework.pdf

Chait M. M. (2010). Gastroesophageal reflux disease: Important considerations for the older patients. World Journal of Gastrointestinal Endoscopy2(12), 388–396. https://doi.org/10.4253/wjge.v2.i12.388

Commisso, A., & Lim, F. (2019). Lifestyle modifications in adults and older adults with chronic gastroesophageal reflux disease (GERD). Critical Care Nursing Quarterly42(1), 64-74. https://doi.org/10.1097/CNQ.0000000000000239

Craven, D. L., Pelly, F. E., Lovell, G. P., Ferguson, M., & Isenring, E. (2016). Malnutrition screening of older adults in the community setting: Practices reported by Australian dietitians. Nutrition & Dietetics73(4), 383-388. https://doi.org/10.1111/1747-0080.12269

Devault K. R. (2017). Management of reflux disease in elderly patients. Gastroenterology & Hepatology3(7), 527–529. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099285/

Dirac, M. A., Safiri, S., Tsoi, D., Adedoyin, R. A., Afshin, A., Akhlaghi, N., & Bacha, U. (2020). The global, regional, and national burden of gastro-oesophageal reflux disease in 195 countries and territories, 1990–2017: A systematic analysis for the global burden of disease study 2017. The Lancet Gastroenterology & Hepatology. https://doi.org/10.1016/S2468-1253(19)30408-X

Ferreira, G. D. O., Moreira, R. P., Felício, J. F., Guerra, F. V. G., Cavalcante, T. F., & Rouberte, E. S. C. (2020). Analysis of the nursing diagnosis risk for falls in older adults with hypertension. International Journal of Nursing Knowledge. https://doi.org/10.1111/2047-3095.12303

Health.vic. (2020). Falls risk assessment tool (FRAT). Retrieved from: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/falls-risk-assessment-tool

Healthcare improvement Scotland. (2020). Braden risk assessment tool. Retrieved from: http://www.healthcareimprovementscotland.org/programmes/patient_safety/tissue_viability_resources/braden_risk_assessment_tool.aspx

Nestle nutrition institute. (2020). MNA norms. Retrieved from: https://www.mna-elderly.com/mna_forms.html

Nursing and Midwifery Board of Australia. (2020). Registered nurse practice standards. Retrieved from: www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Oh, J. H., & Park, E. (2017). The impact of health literacy on self-care behaviors among hypertensive elderly. Journal of Health Education and Promotion34(1), 35-45. https://doi.org/10.14367/kjhep.2017.34.1.35

Poledníková, Ľ., Slamková, A., Solgajová, A., & Zrubcová, D. (2019). Malnutrition in older people in clinical nursing diagnosis. International Journal of Nursing Knowledge21(4), 337-343. https://doi.org/10.32725/kont.2019.040

Ten Cate, D., Ettema, R. G., Huisman‐de Waal, G., Bell, J. J., Verbrugge, R., Schoonhoven, L., & de Man‐van Ginkel, J. (2020). Interventions to prevent and treat malnutrition in older adults to be carried out by nurses: A systematic review. Journal of Clinical Nursing29(11-12), 1883-1902. https://doi.org/10.1111/jocn.15153

 Volkert, D., Beck, A. M., Cederholm, T., Cereda, E., Cruz-Jentoft, A., Goisser, S., de Groot, L., Großhauser, F., Kiesswetter, E., Norman, K., Pourhassan, M., Reinders, I., Roberts, H. C., Rolland, Y., Schneider, S. M., Sieber, C. C., Thiem, U., Visser, M., Wijnhoven, H., & Wirth, R. (2019). Management of malnutrition in older patients-current approaches, evidence and open questions. Journal of Clinical Medicine8(7), 974. https://doi.org/10.3390/jcm8070974

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