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Case study. This assignment will present a holistic profile and discuss the plan of care for a selected patient, within an inpatient setting.

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Introduction

Introduction This assignment will present a holistic profile and discuss the plan of care for a selected patient, within an inpatient setting. This will be through the understanding of the nursing process concluding with the reflection of my learning from assessing and caring for my patient. The purpose of the nursing care plan is that it will enrich me to gain better understanding of the patient's individuality, that is, to see the patient as a whole. It will enable me to understand of the patient's social status, cultural background, economic level, hobbies and special interests which all contribute to the patient's welfare. It will also enable me to understand nursing process, to practice written and verbal expression, to develop observation of the patient and to develop research skills. According to Crisp and Taylor (2005), nursing process is a problem solving approach that enables the nurse to provide care in an organized scientific manner. It also integrates critical thinking and also involves collaboration with the health care team. There are essentially five steps to nursing process: assessment, nursing diagnosis, planning, implementation and evaluation. What is involved in these processes is included in the patient care plan discussed later. The patient chosen is through my clinical placement in one of the largest teaching hospital in South Auckland. The ward provides a culturally safe environment for thirty patients it can house at a time and is a specialized ward for patients with colorectal, breast and stomach complications. Confidentiality is always uphold in this ward and this can be seen by the patients folder being locked in drawers and only health professionals directly caring for the patient gaining access to it. Informed consent had to be taken from the chosen patient to carry out this project on holistic nursing. Patient was informed that any information passed on, either relating to health or private issues will be confidential and the name of the patient won't be revealed at any time. ...read more.

Middle

She is quite independent to do her personal grooming but needs constant reminder and pushing to care for herself. Controlling body temperature Signs of infection Body temperature Presence of mucous in the feces does indicate infection however her body temperature is quite normal at 37.2. Joy has been advised to wipe her hands with antiseptic after using the toilet to control any risk for infection due to Yersinia enterocolitica. Mobilising Balance: sitting, standing, dressing Transferring, walking Aids/prosthesis used Falls risk assessment Dependence/independence Able to walk, around and do stuff for herself. She is quite independent and hardly needs assistance in mobilizing, however, she is restricted to one room so as to control the spread of cross infection. She feels bit wobbly because of her bipedal edema Working and playing Support systems - family, friends, wh�nau, pets Work/study Interests, activities: physical, social, intellectual, religious practices/beliefs Joy is religious and goes to church whenever she can. She visits her son in Australia quite regularly. She is quite proud of her family as she says she has managed to raise quite capable kids. She is quite dependent on her youngest daughter, has no financial difficulties as the husband has left quite a bit of money for her to enjoy her rest of life. She loves her vegetable and flower gardening and loves the art of tapestry. She also loves cooking. Expressing sexuality Grooming requirements Concerns expressed Needs to be reminded on her personal hygiene though she loves her lacy gowns and loves to shop for new good clothes and shoes. Sleeping Hours of sleep, day, night Bedtime - number of pillows Aids to sleep - drink, medications, positioning Sleeps for short period of time. Needs three pillows, two under her head and one to hold. She prefers not to take anything for sleep as she is quite anxious that she may not be able to get up and go to the toilet in time and have a misadventure. ...read more.

Conclusion

I have been part of the group in doctors round and that gave an overall picture of my patient's medical problem and her advancement towards getting better. Thorough documentation is also a valuable source of information to all members of the health team, whether it is the doctor's notes or the nurse's notes. For my client, in one instance, I had noticed that throughout my shift she hadn't drank her jug of water. This I reported to my nurse in charge and she documented that in her nurse's note so that the next nurse to care for Joy would prompt her to drink her water. It is also important to maintain a professional relationship, and I can see that one can easily get too involved with the patient. All I had to remind myself of was that this relationship is essentially a therapeutic relationship whereby there is an explicit time frame and the relationship should end after the process of care giving. I have also realized the importance of families and friends being included in patient care as that are one medium of insuring continuity of patient care. Also having family and friends present, provided tremendous emotional support to my client. Observing the effort that Joy has made to fulfill her goals, her strong faith, lively spirit and brave acceptance of her condition is quite outstanding and I have realized that my encouragement has really worked for her. I would also like to say that I have truly received more than I had given. REFERENCE Allopurinol, 171, Diltiazem, 25, Felodipine, 27, Metronidazole, 252, Metropolol, 36, Microlax, 13, Morphine, 142: Mims, New Ethicals, 2007. Bishop, G. L. P. (2002). Microbiology and infection control for health Professionals: (2nd ed.). NSW, Australia: Parentice Hall. Crisp. J., & Taylor, C. (Eds.). (2005). Potter & Perry's fundamentals of nursing (2nd Australasian ed.). Marrickville, Australia: Elsevier Australia. Marieb, E. N. (2001). Human Anatomy and Physiology: (5th ed.). Boston, New York: Benjamin Cummings. Porth, C. M. (2002). Pathophysiology: Concepts of Altered health status: (6th ed.).Philadelphia: J.B.Lippincott Co. . . ?? ?? ?? ?? ...read more.

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