Challenges with self-care in areas such as grooming and feeding due to neuromuscular deficits

Summative Assessment: Care Plan 1

Patient Bio

This section presents the case of an actual patient this nurse has encountered the patient’s name has been changed to safeguard privacy and maintain confidentiality.

Miss Bo, 71 and single, was seen at the hospital for lethargy and possible loss of attachment. Her younger brother reported that she has been sleeping for prolonged periods and has not been eating lately. The patient’s younger brother, 47, is her main caregiver and is the one buying her food since she is largely homebound. She stays at home alone while her brother works in the day. She can ambulate at home by furniture cruising or crawling, if her lower limbs feel numb. She feeds herself and goes to the toilet by herself but needs assistance with showering and dressing. Presently, she showers only once per week when her relative’s maid comes to assist her. Miss Bo is unemployed and is Buddhist. Medical history includes schizophrenia, diabetes, hypertension, and hyperlipidemia. Two years ago she was also hospitalised for community-acquired pneumonia, weakness, vitamin B12 deficiency, and left hip pain. She denied any feeling of discomfort during the assessment.

Part II: Care Plan

Assessment

In order to assess the patient’s needs, her vital signs were taken and an interview about her medical, social, and family history was conducted at her bedside and with her brother. Previous health records were also accessed to gather relevant data. Guided by the ageing theories, nursing theories, HBM, and the SF, this nurse identified her needs as follows:

1. Miss Bo has not been eating well lately and when she does eat, her brother buys store-bought foods for her. These store-bought foods may or may not have adequate nutrition. Hence, diabetes, hypertension, and hyperlipidemia may resurface or be exacerbated if her diet is not managed well. Along with these, improving her sleeping pattern and adding exercise to her routine, both of which are not happening, can result to better heath.

2. She also has impaired mobility and cruises using furniture or crawls, which puts her at risk for falls and other injuries. Moreover, she needs help with several activities of daily living as she cannot accomplish these on her own. Showering only once a week is especially precarious since it puts her at risk for infections, parasites, and other diseases. Hence, enhancing her mobility can give her a better sense of security

3. Being home ambulant also leads to isolation which can precipitate depression or low mental health. Similarly, lack of interaction with the community impinges on her sense of belongingness. This may result to loneliness and subsequent negative personal narratives, as well as sense of purpose.

4. Addressing the needs of her brother as caregiver is also critical. Should he experience burn-out or fatigue, Miss Bo will also be affected.

Diagnosis

• Possible malnutrition due to refusal to eat

• Challenges with self-care in areas such as grooming and feeding due to neuromuscular deficits

• Impaired physical mobility resulting from neuromuscular deficits

• Impaired balance due to neuromuscular deficits

• Risk for fall and other injuries due to impaired mobility

• Possible skin breakdown because of limited showering

• Risk for depression because of isolation and lack of social interaction

Care plan

Patient Name Miss Bo DOB: 13-May-1947

Baseline recordings

T: 36.5 BP: 124/60

HR: 73 RR: 18

SpO2 96% on RA

Ht: 152 cm Wt: 58.4

BMI: 25.3 BSA: 1.57 m2 Chest XRay: normal

Brain CT: no intracerebral hemorrhage

Mobility:

Sits independently but shows

poor standing balance;

gets dizzy after walking with walking frame support

Further individual or medical information may be needed here if appropriate

N/A

Need Goal Nursing Intervention

1. Improve diet, regular exercise, and appropriate sleeping schedule

** This will improve Miss Bo’s sense of security since she needs to feel free physical harm. Knowing that she is also doing her best to live healthily can add a sense of purpose Short Term

• Miss Bo will follow DM (diabetes mellitus) diet.

• She will perform circuits of gentle exercises that can be done at home.

• Her brother will help her monitor sleeping pattern using a sleeping chart.