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Any nurses?? Who know about care planning!

59 replies

Smurfgirl · 16/04/2007 19:00

I have a question about a care plan I am doing for an assignment. Am using Orem but its more general advice.

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Donbean · 16/04/2007 21:29

OOOH i dont like sputum, dont mind it rattling round in chests and seeing it on xray but dont like it in volume..in front of my eyes. Much prefer closed circuit suction, stringing up the catheter...LURVLY.

snottyshoulders · 16/04/2007 21:30

Loads of reason, love all the social stuff (mainly homeless, drug addicts and asluym seekers get TB) and work in the community so no hanging out in the hospital. And I got to run all my own clinics, just love it!!!
[weird nurse emoticon]
What do you do?

Donbean · 16/04/2007 21:31

Sorry Smurfy, fellow nusres with strange passions always intrigue me!

Smurfgirl · 16/04/2007 21:31

Raymond Smith is a 62 year old man who works as a supervisor in a dock-side warehouse.

He lives with a wife and two adult sons in a small terraced house in an inner-city environment within the UK. He also has one adult daughter who lives in Sydney in Australia with her partner and six-year old daughter. Raymond has a close relationship with his family.

Raymond has never travelled abroad until he visited his daughter a few months ago. Raymond was born locally and has an extensive network of family and friends.

Raymond is 1.70 metres tall and 80 kg in weight; he is of average build and has a moderately physical job. He feels he is slightly overweight but in better condition than many of his workmates. However, Raymond has noticed that he has unintentionally been losing some weight over the past two months. People that see Raymond on an occasional basis have commented on his weight loss and change in appearance.

Raymond has been in reasonable health through-out his life. He enjoys watching sport and supports a local football team. He socialises with friends on Saturday nights and drinks about six pints of beer a week. He enjoys doing word puzzles and general knowledge crosswords.

Raymond is increasingly concerned about the weight-loss as it has been accompanied by other subtle changes in his health. Raymond?s sleep is often disturbed and he has suffered night sweats. Raymond is suffering from general malaise which he attributes to his altered sleep pattern.

Raymond has developed a persistent productive cough during the past few weeks. He was concerned about this development and immediately stopped smoking. This proved surprisingly easy as he only smoked on social occasions and he found that his family and friends were very supportive. However, Raymond was disappointed that his productive cough persisted; moreover his sputum has occasionally been streaked with blood.

Raymond has rarely visited his GP and is reluctant to seek medical advice. However, his family had noticed that Raymond was becoming withdrawn and irritable. Initially, this was attributed to stopping smoking. However, Raymond eventually admitted to his wife that he thought he had lung cancer and he had been trying to suppress his health concerns.

Raymond arranged to visit his GP who arranged a chest x-ray and a subsequent appointment with a respiratory physician.

Raymond visited the chest clinic four days later. The Specialist Registrar told Raymond that he suspected that Raymond may have pulmonary tuberculosis. Raymond vaguely recalled that several children that he grew up with had suffered from tuberculosis. However, he had no understanding of the disease or prognosis.

The Specialist Registrar was concerned that Raymond was weak, pyrexial and short-of-breath. Consequently, Raymond agreed to be admitted to a local Infectious Diseases Unit (IDU) where he could undergo medical investigations and receive treatment and nursing care. Raymond was relieved to be admitted to hospital as he had struggled to use the upstairs toilet and bathroom in his home. He felt unkempt and worried constantly about getting to the toilet on time to urinate. He has not had his bowels open for two days.

The Chest-ray revealed cavitations in the right and left upper lobes. A sputum sample was taken at the out-patients clinic and a smear was analysed, which revealed live mycobacterium tuberculosis. This positive smear meant that Raymond?s sputum was considered to be infectious.

Upon admission to the IDU, Raymond was admitted to an isolation cubicle that had en-suite bathroom and toilet. His primary nurse was concerned about Raymond?s physical condition and suggested that he should rest on the bed.

The Medical SHO examines Raymond and prescribes isoniazid and rifampicin, paracetamol and oxygen at 28% via a venturi mask.

Raymond?s base-line vital signs were:
Pulse 88 regular - normal strength
Blood Pressure 180/80 mmHg
Respiration 24 shallow
SpO2% 90% on 28% oxygen via a venturi mask
Temperature 38.6ï‚°C

Raymond is relieved that he does not have lung cancer and he has been reassured that tuberculosis is treatable. However, Raymond and his family are shocked at his weak condition and infectious-status. Raymond?s wife and children are anxious about their own health and the risk of contracting tuberculosis.

Task

Using Orem?s Self Care Model as a framework:

Assess
Plan
Devise an implementation
Suggest mechanisms for evaluation

You cannot use a critical care pathway: you must develop an individualised plan of care for Raymond that will address his acute and continuing needs. The care plan must be underpinned by evidence based practice and follow the philosophy of Orem?s self-care model.

You should be able to rationalise the process that you have undertaken with reference to the framework (Orem?s model and the problem-solving approach).

You should have a particular understanding of the prescribed medication and the rationale for any intervention that you utilise to treat the pyrexia.

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Donbean · 16/04/2007 21:31

Critical care sister.

Smurfgirl · 16/04/2007 21:32

I love communty stuff fancy a gastro ward actually when I qualify (more likely to be unemployed!!).

Donbean - next placement is critical care, am hoping and praying for ICU!

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Donbean · 16/04/2007 21:33

OOOh fab! Just hope seeing your friend hasnt put you off ICU x

Smurfgirl · 16/04/2007 21:35

Not at all donbean. I am very interested in a career in critical care i think, enjoy looking after very sick patients. HDU would be fab too i think.

Critical care placement can be theatres but I reallllllllllly (x billion) don't want that, jjust finished a placement in day surgery/angio and it was so BORING for me.

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snottyshoulders · 16/04/2007 21:36

Ok!!!!!!!!!! WEEEEEHHY
[professional emoticon]
Firstly he's 65 so likely to be reactivation (don't worry too much about that) but it basically means that a) he's had it before or b) he's been in contact with it. So first thing would be his medical history. HAs he had BCG? ANy previous contact? TB in family?
Secondly and very importantly, he's just flown on a long haul flight, so assuming that his sputum is smear positive (ie infectious) and he is actually coughing you need to inform the flight company (usually public Health would do this). He potentially could have infected people on the flight (as its over 8 hours)
Weight loss- establish his previous weight and history of weight loss. This will be put back on when on treatment
reduced sleep- probably due to NIGHT SWEATS- again this will improve on treatment
I'll stop for a sec till you've got that!!!

snottyshoulders · 16/04/2007 21:38

soory crossed posts!

saralou100 · 16/04/2007 21:39

hi smurfgirl.... i think whats jumping out to me is your saying some stuff is too medical, but isn't that what we do?? i would definitely include them bits!!

what other info you got for us? what other symptoms?

a chance to use my brain!!!!

Smurfgirl · 16/04/2007 21:39

I posted the scenario further down.

Is it a nursing role to report to public health?

When will the night sweats stop?

The focus needs to be on self caring, I can RLT plan but I think I am finding it harder because its Orem.

V.v.helpful this, much appreciated.

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Donbean · 16/04/2007 21:39

You are REALLY excited aren't you snotty!!!

Smurfgirl · 16/04/2007 21:42

If he is not self caring is his lack of it due to motivation/skills/knowledge - keep seeing this mentioned in Orem, but he is not caring becausehe has TB surely??

Am normally v.v.slack about things but am being assessed by v.strict tutor for this careplan.

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Smurfgirl · 16/04/2007 21:42

Oh and he has R side pain in his chest and paracatamol is not easing it pain scale is 4-8.

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snottyshoulders · 16/04/2007 21:48

Thanks saw that
Yes the nurse has to notify public health (actually its the doctors job but widely recognised thats its often missed) you would use a green notification form to do this. Signed by the doctor
The HUGE part of the nurses role is reassurance and education- reassuring that he WIll get better and its curable but its takes a long time (TB meds are for at least 6 months, usually 6 month course of often about 12 tablets) in is up to the patient to make sure he takes his medication DAILY to get better, in TB comppliance is a HUGE PROBLEM. NOt taking meds daily for the full course can cause DRUG resistance (YOU MUST INCLUDE THIS)
THe night sweats will stop but may take a good few weeks until meds have kicked in.
HE needs to write down ALL the people he has had prolonged contact with (including realtives in Oz) and the immediate family will have to be CONTACT TRACED. by having MANTOUX TEST and possibly chest x ray. You would need to ask him for any symptomatic close friends or family and get them screened urgently, especially children (urgent- next clinic) and ill people, people he lives with (next clinic) if they were all clear thats probably all, but if anyone wwas infected a wider group of people would have to be screened (ie casual contacts) and of course the plane passengers NEED TO BE CONTACTED.....It's up to the patient to tell you the nales of these people.

saralou100 · 16/04/2007 21:50

you could think in terms of plan to build him up to self caring.

notes i've made are..

nutrition/elimination

sleeping difficulties

pyrexia

sob/cough/oxygen therapy

infection control

personal hygene

pain

now try thinking what nursey things to do under these headings

i know nothing about orem though, i'm in mat leave denial... hth x

saralou100 · 16/04/2007 21:52

i love care pathways... none of this crap!!

snottyshoulders · 16/04/2007 21:55

Get higher analgesia sorted by doc's, ask patient to inform nurse of pain control, maybe by using pain scale, as you mentioned, the patient would have to take control of this (self caring) if he was up to it.
TB can make people very unwell and would probably make him be very tired and not motivated BUT TB has a HUGE stigma related to it and he maybe feeling really shit due to having TB (don't put shit ) People, particularly of his age group knew people that died of TB all the time, there was a stigma because it ued to affect the poor, the stigma still stands now, he would/could be feeling very depressed about having a 'poor' or infectious disease. AND he's in isolation which is known to be a huge problem for patients.
He needs to ne educated but IMPORTANTLY so do hi family (obviously if he gives permission). TB is difficult in regards to confidentiality due to contact tracing....

snottyshoulders · 16/04/2007 21:57

Oooh don't forget the information about the medication as well, they have terrible side effects
He would also be allowed to go home after two weeks of medication as he wouldn't be infectious after that time...

Smurfgirl · 16/04/2007 21:58

Thanks.

I have done a specific goal about infection control and talked about wider public health issues.

Have done ones for hygiene, breathlessness, nutritional status, rest

have included mobility in rest

is pain to be expected?

he is also hypertensive

(i have read up on TB I promise!!)

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snottyshoulders · 16/04/2007 22:00

The main emphasis of self caring in this scenario would be client being able to take medication himself as its soooo important that this is done daily for six months. There are 12 tablets on average. he would have to know side effects and what each one did...(do you want me to go into meds?)
He will start to feel better as medication works, so therefore be able to take on more self care.

snottyshoulders · 16/04/2007 22:04

Pain is sometimes an issue but obviously he has had TB untreated for some time, hence the cavitations and blood in sputum, the pain is not a common symptom and should ease with treatment...He needs good pain control though, and paracetamol wouldn't be enough.

It's important obviously that his BP is well controlled and for the life of me I can't think if theres a drug interaction there, if he's on meds for hypertension?

Smurfgirl · 16/04/2007 22:06

Have talked about teaching to take meds independently.

Don't need to go into meds specifically unless the side affects need care plans??

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Smurfgirl · 16/04/2007 22:07

I got the impression that the hypertension was new - personally 180/80 would not worry me too much but I have specifically written down about it in my notes which makes me worry.

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