Case study 2: Susan Rossi is a

Case study 2: Susan Rossi is a 76 year old Italian women who has just been admitted to an Aged care facility. She has Multiple Sclerosis, she has very poor memory and English is her second language. Her past Medical History includes very limited Range of movement (ROM) of both lower legs, Percutaneous Endoscopic Gastrostomy (PEG) tube with TDS bolus feeds. She also has limited ROM with her left shoulder. She has been tolerating small amounts of level 3 thickened fluids, but her PEG feeds are causing nausea and diahorrea. Due to Multiple Sclerosis she is no longer able to ambulate and is non-weight bearing. She is incontinent wears pads and is refusing IDC, she therefore has developed severe excoriation to her groin which is now painful and bleeding. She has a very supportive family and grandchildren that come and visit her every day at lunch time. In reference to the above case study – construct a Nursing Care Plan including: Six Nursing Diagnoses for case study At least two Goals and Expected outcomes for each Nursing Diagnosis Discuss the Nursing Interventions for each Nursing Diagnosis, giving the rationale for each Nursing Intervention Evaluation (how would you evaluate your nursing Care) for each Nursing Diagnosis In addition to the Nursing Care Plan, Provide a written Nursing handover using the ISBAR tool (Identification Situation Background Assessment Recommendations) which includes providing briefly, the information the nurse on the following shift would need to provide effective nursing care. NB: When formulating your Nursing Care Plans x 2 you may consider some of the following key areas of Nursing Care: Activities of Daily Living (ADLs) including Toileting and Hygiene including Mouth Care, Mobility plan including Falls risk assessment, Nutrition & Fluid intake requirements Sensory and cognitive deficits Mental Health issues & well being Prevention of post-operative (post -op) complications Promoting exercises ,rest and sleep, physical comfort Protecting and improving skin integrity Pain management Considerations for respiratory support and circulation Address Underlying medical conditions ISBAR Handover I (Introduction/Identify-Introduce yourself and your designation. Introduce the patient (name, age, and gender), reason for admission to hospital and diagnosis (if known).) S (Situation-Admission diagnosis and current condition (deteriorating, stable, improving) B (Background-Relevant past medical history, Allergies, Current Medication, social supports/services) A (Assessment-Systematic clinical assessment of the patient using a body systems approach, risk assessment findings, functional assessment, psychological assessment, responses to nursing interventions and medical treatments. Actual and potential problems R (Recommendations-Required nursing interventions, Medical and Allied Health orders, pending procedures/diagnostic tests – dates and times if known, Discharge planning issues)

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