AgentNeutronRam214
Instructions CLIENT ASSESSMENT Read the case study on Mrs. Jones….
Instructions
CLIENT ASSESSMENT
Read the case study on Mrs. Jones. Complete a nursing assessment using these concepts: Client,
Environment, and Health.
? Follow the “Nursing Assessment Tool: A Systems Approach” to insert findings from the case
study.
? Use the “Nursing Assessment Form” to organize your data.
? Complete medication research as outlined in the case study
NURSING CARE PLAN
Use the “Nursing Care Plan” form to complete this care plan. The following elements should be
included in your care plan:
Nursing Diagnosis and Planning
Write three (3) nursing diagnoses (diagnostic labels), utilizing Ackley and NANDA as
guidelines. Identify one of each of the following in your diagnoses: an actual problem, a
risk/potential problem and a wellness/health promotion-teaching focus. Prioritize your nursing
diagnoses in order of most important to least important including rationale for your decision.
Write one (1) SMART client goal/expected outcome for each nursing diagnosis. The client goal
must be written as a SMART goal.
Implementation of Nursing Interventions
Select two (2) nursing interventions for each client goal/ expected outcome.
Provide evidence from the literature to support your rationale for each nursing intervention.
Nursing Evaluation
Write evaluation criteria for each nursing intervention that would be used to determine if the
client achieved each client goal/expected outcome.
Case Study: Mrs. Jones
Mrs. Martha Jones, 82 years old, currently lives with her single son in a small town. For
financial reasons she has lived with two of her four grown children for many years. She lives
close to a community that can provide health services such as a hospital, primary care clinic,
physiotherapy, occupational therapy and recreational opportunities. Specialist appointments
require travel to a larger center.
Mrs. Jones grew up in a small farming community and has moved around many times during her
life because of work. For financial reasons she was not able to retire until she was 72 when
health reasons forced her to leave her job. She lives on a fixed pension income but because she
lives with her son, the pension amount currently is able to meet her personal and medication
needs. She is mostly independent for personal care needs, cooking and housekeeping but the
arthritis in her hands provides challenges with some of the activities of daily living (ADLs). She
is still able to drive. Due to her health issues and their cumulative effects, she is moving into a
Supportive Living facility for closer access to ongoing medical care. As a student nurse, you are
in the process of documenting the admission history and creating a care plan in preparation for
this move.
A long-time smoker, Mrs. Jones quit smoking in her late 60s. She often finds herself ‘out of
breath’ and is not able to sustain activities for long periods of time. Walking short distances
increases the shortness of breath. She advises that her feet are often very swollen and that she
needs to sit down often to try and decrease the swelling. Advises that she is up at night often to
void. She also relates a history of gout which mostly affects her feet. Mobility is becoming more
challenging because of her shortness of breath, arthritis and gout. Her stomach gives her
‘trouble’ and is prone to periods of nausea. She also experiences diarrhea on a regular basis.
Experiences fatigue frequently. Has had a weight loss of about 15 pounds over past year. Due to
all of her health issues, she is moving into a Supportive Living facility for closer access to
ongoing medical care.
She has had many chest x-rays to monitor her lung condition and recently had arterial blood
gases taken by a Respiratory Therapist. The results showed that she was only 1% above the level of requiring home oxygen. Her care provider has decided that she will need to have pulmonary
function tests completed with a specialist. Has had numerous testing for her ‘stomach’ trouble
and diarrhea.
Medical History:
? Hypertension – generally well controlled on current medications.
? COPD
? Emphysema
? Gout
? Mild Chronic Kidney Disease
? Mild Arthritis
? Intermittent bouts of nausea/diarrhea
Immunization Status:
? 3 doses of Covid Vaccine
? Influenza vaccine irregularly but did take one last year
? Pneumococcal 23 Vaccine – 10 years ago
? Tetanus – 15 years ago
? Mantoux test – 15 years ago
Recent Laboratory Results:
? Gas Panel
pH; Arterial 7.37
Carbon Dioxide; Partial Pressure; Arterial 49 mmHg
Oxygen; Partial Pressure; Arterial 72 mmHg
Bicarbonate; Arterial 29 mmol/L
Base Excess; Arterial 3 mmol/L
Oxygen Saturation; Arterial 94%
? Urinalysis Panel
Clear; Yellow
Negative for Glucose, Ketones, Hemoglobin, Leukocytes, Nitrites, Protein
? Blood Work
Natriuretic Peptide B (BNP) 135 ng/L
CBC – All normal.
Hemoglobin 128 g/L
Random Glucose 5.6 mmol/L
Creatinine 208 umol/L
Glomerular Filtration Rate (eGFR) 19
Urea 12.7mmol/L
Electrolytes (Ca+; Na; Mg; K+) – Normal range.
Hemoglobin A1c (HbA1c) 6.3%
Current Continuous Medications:
? Metoprolol 50 mg – one tablet twice daily
? Perindopril-Indap 8-2.5 mg – one tablet daily
? Furosemide 20 mg – one tablet daily
? Spiriva 18 mcg handihaler – once daily
? Maglucate 500 mg – one tablet daily
PRN Medications:
? Salbutamol 100 mcg inhaler – 2 puffs every 4 hours as needed
? Prednisone 50 mg – one tablet daily for 5 days
? Doxycycline 100 mg – one tablet BID when prescribed for infection
? Colchicine 0.6 mg – one tablet twice daily when needed
? Pantoprazole DR 40 mg – one tablet twice daily as needed
Current Physical Assessment:
? Vital Signs: T – 36.8?C; P – 90 slight irregular; R – 26. B/P – 126/84; SaO2 – 88% on
room air.
? Lungs: Cough; SOB; fine scattered crepitus; Lung sounds slightly distant.
? Heart: S1 and S2 noted – Soft S3. Irregular rate.
? Extremities: Heberden’s nodes right and left hands. 3+Pedal Edema bilaterally.
Nursing Assessment Form
Client Name: ___________________ Medical Diagnosis: ___________________________
Client Perception of Health Needs: ________________________________________________
Client Goals for Health: _________________________________________________________
Allergies
(food, medication,
environmental)
Medications
Dietary
considerations
Vital Signs T ____ P ____ R ____ BP _______ O2 sats _____ Pain rating ______
HEALTH ASSESSMENT DATA
Physiological Variable
General Appearance/Mental State Cardiovascular System
Respiratory System Gastrointestinal System
Urinary System Sensory Systems
Nervous System Integumentary System
Musculoskeletal System Reproductive System
Endocrine System
HEALTH ASSESSMENT DATA
Spiritual Variable (Environment) Developmental Variable (Environment)
Sociological Variable (Environment) Psychological Variable (Environment)
Determinants of health impacting client’s health (Environment)
Interdisciplinary Team Members
Health Priorities
Client Strengths
HEALTH PRIORITIES BASED ON ASSESSMENT DATA
Summarize findings from assessing all concepts of nursing metaparadigm.
Summarize and prioritize findings to identify most significant actual/potential wellness/problems.
NURSING DIAGNOSIS (DIAGNOSTIC LABELS) X 3 Use assessment data to establish a nursing diagnosis that reveals: Actual/ Problem
Risk/Potential
Wellness/Health Promotion-Teaching
PLANNING
Client Goals: General statement about the client’s goal
? Specific
? Measurable
? Attainable
? Realistic
? Time-based
INTERVENTIONS
List Interventions:
Select nursing interventions to meet the goals set, and to change or
maintain health status.
Rationale for Interventions:
Provide rationale for selection of nursing interventions and use
appropriate literature such as text, articles, and internet sites to support
choices.
EVALUATION
Achievement of Expected Outcomes:
Assess goal achievement and reasons, and set
new plan as needed.
Client Responses and Findings:
Describe why goal was met or not met.
Summarize the effectiveness of nursing
interventions.
Further Nursing Actions:
Assess evidence that outcome was met.
Readjust nursing care plan as necessary.
HEALTH PRIORITIES BASED ON ASSESSMENT DATA
NURSING DIAGNOSIS
PLANNING
Client Goals:
INTERVENTIONS
List Interventions: Rationale for Interventions:
EVALUATION
Achievement of Expected Outcomes: Client Responses and Findings: Further Nursing Actions:
