self in the planning and resolution process to bring about awareness of his present condition and how to go about making lifestyle changes to resolve the painful issues and restore good health. By involving the patient in the clinical process, the care rendered would be less stressful because the patient would make better adjustments where food, hygiene and other activities were concerned. The symptoms experienced by the patient were severe spasms of pain in the umbilical area accompanied by nausea, and feelings of warmth, sweat and vomiting. From these symptoms, the diagnosis drawn was that the patient suffered from gastroenteritis.
The delivery of care was customized according to the needs of the patient in order to ensure better adjustment and better health outcomes. The format used for this clinical case was SOAP (Subjective, Objective, Assessment and Plan) format in order to arrive at the right diagnosis.
Subjective data such as the health issues of the patient, the background he came from, occupational and financial status, substance abuse, emotional stability and information of other social activities was collected through dialogue with the patient and other friends and members of his family. Subjective data included that the patient was a male 60 years of age and was a retired school teacher with a Master’s degree in education. He and his wife live off a state teacher’s pension, though his wife continues to work at a grocery store. They have two children, a son and daughter who do not live with them. He is also covered by health insurance. He is a sociable individual because he showed inclination of wanting to involve himself in community work. He denies substance abuse but admits to drinking wine and eating fast foods on a regular basis. His primary complaint was that he had acute pain around the umbilical region accompanied by nausea, queasiness, sweating and a feeling of vomiting and these symptoms prevailed for the past 24 hours before his visit ...
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(“Care Plan Assignment Example | Topics and Well Written Essays - 1250 words - 1”, n.d.)
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(Care Plan Assignment Example | Topics and Well Written Essays - 1250 Words - 1)
“Care Plan Assignment Example | Topics and Well Written Essays - 1250 Words - 1”, n.d. https://studentshare.net/nursing/687903-care-plan.
Reputed, peer reviewed academic journals and books have been researched. The case of Mrs. Blackwell is mainly under the category of geriatric nursing care. Her chief problem is fear of fall along with lack of mobility. The paper on this case consists of 4 diagnoses and related goals for the patient.
Jones is a widow of eighty years old and resides alone. She and her next door neighbour used to visit the social club frequently as a leisure activity to play bingo. However, the lifestyle enjoyed by Mrs. Jones got disrupted after she was diagnosed with the problem of falls, sever osteo-arthritis and a hip replacement need.
Advanced age slows the healing process.
Nothing is disclosed about the nature of the client except for her age, BP, pulse and temperature. Obviously, the patient will be quiet and drowsy as a result of the anesthetic effects for a day or two. The patient is dependent on nurses to carry out personal functions such as changing clothes, cleaning and toilet needs.
Overt cues may be client statements as “I am going to kill myself.” Covert cues may be client statements as “Nothing seems helpful, I want to have a good rest” (Videbect, p.121).
Encourage the client to have an “emotion notebook”
The patient is referred to an urologist for further genitourinary work up, to a cardiologist for managing the grade II/VI systolic murmur, and finally the patient will be referred to a gastroenterologist due to the presence of blood in stool.
The patient presents with