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Nursing Assessment

 

Mr Erik Thomasson is a 78-year-old widow of 9 months. He lives alone in a retirement village in the Perth suburb of Karrinyup. His two children live with their families in Busselton. He is very lonely and misses his children.  He has always enjoyed cooking for his wife and family; however, now that he is alone, he does not cook for himself. As a result, he has developed irregular eating patterns and tends to prepare soup-and-toast meals. He gets little exercise and has had bouts of insomnia since his wife’s death. For the past month, Erik has been having a problem with constipation. He states he has a bowel movement about every 3 to 4 days and his stools are hard and painful to excrete. Erik decides to attend the health fair sponsored by the retirement village and seeks assistance from the RN that you are buddied with on your community placement as a nursing student.

Physical Examination Height: 162 cm, Weight: 65 kg, Temperature: 36.2°C, Pulse: 82, Respirations: 20/minute, Blood pressure: 128/74 mm Hg, Active bowel sounds, abdomen slightly distended

Identify the issues for Erik.  List here all the concerns you have for this patient.  There are lots!

 

 

 

Cluster the identified issues together into small meaningful groups. That is, what clinical manifestations or concerns go together. 

 

 

 

Identify the main problems for Erik.  Ensure you write it in the correct format – go back to the week one ILA on ADPIE or the book if you need some guidance. 

Eg -Format -  at risk of social isolation R/T death of his wife

 

 

Your nursing diagnosis should be related to constipation! Complete the following for Erik in relation to your main concern of constipation.

Goal(s) – (That is – What do you want to achieve for Erik in relation to his constipation?)

 

 

 

 

Plan of care – list interventions (4 as a minimum) and explain the rationale for care that you would implement for Erik. 

Intervention - 

Rationale for care -   

 

Intervention - 

Rationale for care -   

 

Intervention - 

Rationale for care -   

 

Intervention - 

Rationale for care -   

 

Evaluation of care (That is – What outcomes do you want to see in Erik if your interventions have been successful?)

 

Consider the following:

Ms Sally O’Connor is an 18-year-old student who is attending the university health clinic for the first time.  She is complaining of urgency and frequency on voiding. Outline areas for further subjective data collection that you would ask Ms O’Connor.

 

 

 

Mr Miller is a 75-year-old widower who has had prostate surgery for benign prostatic hypertrophy. He thought his problems would be over, but now he is experiencing continual dribbling of urine. He has been trying to deal with the problem by using an absorbent pad in his underwear, but he feels as though everyone is aware of it. The embarrassment of having an odour often keeps him at home. He has given up going to the golf club, which he usually attends three times per week.

A. Outline the areas for further assessment of his problem.

To start you off I have listed one for you.

Skin assessment

 

 

 

 

 

B. Identify all the areas of care that need to be considered for Mr Miller.  To start you off I have listed one for you.

Skin care

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING NPU1202

 

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