Nursing Care Plan for Ms. Elanor Johanson: A Comprehensive Guide Case study

Introduction

This essay discusses the case of Ms. Elanor Johanson, a 64-year-old woman who recently underwent hip surgery and is experiencing multiple physical and psychosocial challenges. The goal is to provide a comprehensive nursing assessment, including pertinent physical and psychosocial assessments, relevant questions to ask the patient, education for the patient and caretakers, anticipated lab tests, nursing diagnoses, and SMART goals. To support this discussion, references from relevant sources between 2017 and 2021 will be cited in APA format.

Pertinent Physical and Psychosocial Assessments

Upon Ms. Johanson’s recent discharge from the hospital, a focused physical and psychosocial assessment is crucial to address her complex health needs. Her current vital signs, including a blood pressure (BP) of 100/70, pulse (P) of 60 bpm, respiratory rate (RR) of 12, temperature of 98.7 degrees F, and oxygen saturation (SpO2) of 95% on room air, require close monitoring (Smith et al., 2019).

Physical Assessment:

Vital Signs: Continuously monitor vital signs, as they can provide valuable information regarding medication effectiveness and overall health status (Potter & Perry, 2020).

Pain Assessment: Employ a pain scale, such as the Numeric Rating Scale, to assess the location, severity, and changes in Ms. Johanson’s pain (McCaffery & Pasero, 2019). The grogginess and sleepiness reported by the patient warrant further evaluation of her pain management plan.

Surgical Site Inspection: Regularly inspect the surgical site for signs of infection, including redness, swelling, or drainage (Ignatavicius & Workman, 2018).

Abdominal Assessment: Given the patient’s complaints of an upset stomach and constipation, perform a thorough abdominal assessment to identify any tenderness or distention (Jarvis, 2020).

Neurological Assessment: Evaluate the patient’s level of consciousness, orientation, and cognitive function, as changes in these areas could be contributing to sleep disturbances and daytime fatigue (Lewis et al., 2021).

Psychosocial Assessment:

Mental Health Evaluation: Given Ms. Johanson’s history of Major Depressive Disorder (MDD), assess her mood, emotions, and any signs of depression or anxiety (American Psychiatric Association, 2017).

Substance Use Assessment: Inquire about the extent and frequency of alcohol consumption, as indicated by the presence of empty wine bottles in her home (Substance Abuse and Mental Health Services Administration, 2019).

Sleep Pattern Assessment: Explore Ms. Johanson’s sleep patterns, disturbances, and any contributing factors, such as medication side effects or anxiety (National Sleep Foundation, 2018).

Social Support Assessment: Identify the patient’s support system, with a particular focus on her daughter’s role in caregiving (Dwyer & Coward, 2020).

Functional Status Assessment: Determine Ms. Johanson’s ability to perform activities of daily living, such as bathing, dressing, and mobility (Berman et al., 2018).

Pertinent Questions for the Patient

To gather essential information and address Ms. Johanson’s health concerns effectively, several pertinent questions need to be asked:

1. “Can you describe your pain in more detail, such as its location, type, and any changes since leaving the hospital?” (McCaffery & Pasero, 2019).
   • Rationale: This question aims to assess the adequacy of pain management and the need for adjustments, considering her grogginess and sleepiness.
2. “How much wine have you consumed recently, and how often?” (Substance Abuse and Mental Health Services Administration, 2019).
   • Rationale: This question addresses the potential issue of alcohol consumption and its impact on her health, especially when combined with medications.
3. “Tell me about your sleep patterns and any difficulties you’ve experienced.” (National Sleep Foundation, 2018).
   • Rationale: This question explores sleep disturbances and their possible causes, considering her reported daytime fatigue and sleeplessness at night.
4. “Have you been taking your medications as prescribed, including the Zoloft and Lisinopril?” (Potter & Perry, 2020).
   • Rationale: Ensuring medication adherence is crucial for managing chronic conditions and mental health, and non-adherence can lead to adverse outcomes.
5. “Can you describe any changes in your appetite, bowel movements, or energy levels since the surgery?” (Jarvis, 2020).
   • Rationale: This question helps assess gastrointestinal and nutritional issues post-surgery, considering her upset stomach, constipation, and reported fatigue.

Patient and Caretaker Education

Patient and caretaker education are vital components of nursing care. In Ms. Johanson’s case, the following topics should be addressed:

Pain Management: Educate Ms. Johanson and her daughter about the importance of effective pain management and the need to communicate any changes in pain levels promptly (McCaffery & Pasero, 2019).

Alcohol Consumption: Discuss the potential risks of alcohol consumption, especially when combined with medications, and offer resources for alcohol cessation (Substance Abuse and Mental Health Services Administration, 2019).

Sleep Hygiene: Provide guidance on improving sleep hygiene, such as maintaining a regular sleep schedule and avoiding alcohol and caffeine close to bedtime (National Sleep Foundation, 2018).

Medication Adherence: Emphasize the importance of taking medications as prescribed and inform them about potential side effects and drug interactions (Potter & Perry, 2020).

Nutrition and Hydration: Offer advice on maintaining a balanced diet and encourage adequate fluid intake, especially to alleviate constipation (Berman et al., 2018).

Anticipated Lab Tests

Several laboratory tests should be anticipated to assess Ms. Johanson’s health status accurately:

Complete Blood Count (CBC): To assess for signs of infection or anemia (Ignatavicius & Workman, 2018).

Basic Metabolic Panel (BMP): To monitor kidney function and electrolyte levels (Berman et al., 2018).

Liver Function Tests (LFTs): To evaluate liver health and assess the impact of alcohol consumption (Lewis et al., 2021).

Urinalysis: To check for signs of urinary tract infection or kidney issues (Jarvis, 2020).

Medication Levels: Monitor the levels of prescribed medications in the bloodstream, if necessary (Potter & Perry, 2020).

NANDA Nursing Diagnoses and Interventions

To guide Ms. Johanson’s care effectively, the following NANDA nursing diagnoses and associated interventions are identified:

Acute Pain related to surgical incision and medication side effects:

• • Interventions:
    • Administer pain medications as prescribed.
    • Educate the patient on pain management techniques, including deep breathing exercises (McCaffery & Pasero, 2019).
    • Monitor and document pain levels regularly.

Disturbed Sleep Pattern related to post-surgery discomfort and medication side effects:

• • Interventions:
    • Encourage a consistent sleep schedule (National Sleep Foundation, 2018).
    • Promote relaxation techniques before bedtime.
    • Collaborate with the healthcare team to adjust medication timing.

Impaired Physical Mobility related to hip fracture and surgical procedure:

• • Interventions:
    • Assist with physical therapy exercises (Berman et al., 2018).
    • Ensure a safe environment to prevent falls.
    • Encourage gradual mobilization as per the physician’s orders.

Risk for Constipation related to opioid use and decreased mobility:

• • Interventions:
    • Encourage adequate fluid intake and dietary fiber (Jarvis, 2020).
    • Administer prescribed laxatives or stool softeners.
    • Educate the patient on the importance of regular bowel movements.

Risk for Depression related to chronic illness and recent surgery:

• • Interventions:
    • Monitor mood and emotional well-being (American Psychiatric Association, 2017).
    • Encourage social engagement and support from family and friends (Dwyer & Coward, 2020).
    • Collaborate with a mental health specialist for evaluation and treatment.

Goals for Ms. Johanson (SMART Goals)

To guide Ms. Johanson’s care effectively and measure her progress, SMART goals are established:

Pain Management:

• • Specific: Achieve a pain level of 3/10 or less (McCaffery & Pasero, 2019).
  • Measurable: Pain levels will be assessed and documented every 4 hours.
  • Attainable: Adjust pain medications as needed to achieve the goal.
  • Realistic: Adequate pain control enhances recovery and quality of life.
  • Time-Bound: Within 48 hours, pain should be consistently at or below 3/10.

Improved Sleep Patterns:

• • Specific: Achieve 6-8 hours of uninterrupted sleep per night (National Sleep Foundation, 2018).
  • Measurable: Sleep patterns will be recorded daily.
  • Attainable: Implement sleep hygiene measures and medication adjustments.
  • Realistic: Quality sleep supports physical and emotional recovery.
  • Time-Bound: Within one week, Ms. Johanson should experience improved sleep.

Enhanced Mobility:

• • Specific: Achieve independent ambulation with assistance devices (Berman et al., 2018).
  • Measurable: Document mobility progress and assistive device usage.
  • Attainable: Collaborate with physical therapists for rehabilitation.
  • Realistic: Regaining mobility is essential for independence.
  • Time-Bound: Within three weeks, Ms. Johanson should achieve this goal.

Conclusion

In conclusion, a comprehensive nursing assessment of Ms. Elanor Johanson is essential for addressing her physical and psychosocial challenges post-hip surgery. By utilizing appropriate assessments, asking pertinent questions, educating the patient and caretakers, ordering relevant lab tests, identifying nursing diagnoses, and establishing SMART goals, healthcare professionals can provide patient-centered care and support Ms. Johanson’s recovery effectively. This holistic approach ensures that Ms. Johanson receives the necessary care and education to promote her well-being and improve her health outcomes.

References

American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.

Berman, A. et al. (2018). Kozier & Erb’s Fundamentals of Nursing (10th ed.). Pearson.

Dwyer, J., & Coward, D. D. (2020). The process of nursing research: Understanding evidence-based practice (4th ed.). Oxford University Press.

Ignatavicius, D. D., & Workman, M. L. (2018). Medical-surgical nursing: Patient-centered collaborative care (9th ed.). Saunders.

Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Saunders.

Lewis, S. M. et al. (2021). Medical-surgical nursing: Assessment and management of clinical problems (11th ed.). Elsevier.

McCaffery, M., & Pasero, C. (2019). Pain: Clinical manual (3rd ed.). Elsevier.

National Sleep Foundation. (2018). Sleep hygiene.

Potter, P. A., & Perry, A. G. (2020). Fundamentals of nursing (10th ed.). Elsevier.

Smith, J. et al. (2019). Nursing assessment and care planning. In L. Swearingen (Ed.), All-in-One Nursing Care Planning Resource (5th ed., pp. 1-26). Mosby.

Substance Abuse and Mental Health Services Administration. (2019). TIP 45: Detoxification and Substance Abuse Treatment. 

FAQs: Comprehensive Nursing Assessment and Care Plan for Ms. Elanor Johanson

1. What is the purpose of this paper?

• This paper serves as a comprehensive guide for conducting a nursing assessment and creating a care plan for Ms. Elanor Johanson, a patient who recently underwent hip surgery.

2. Who is Ms. Elanor Johanson, and what is her medical history?

• Ms. Elanor Johanson is a 64-year-old woman who experienced a right femoral fracture of her hip and underwent emergency surgery. Her medical history includes Chronic Kidney Disease (CKD) – Stage 3, controlled hypertension (HTN), and Major Depressive Disorder (MDD).

3. What assessments and techniques are used in this care plan?

• The care plan includes physical assessments such as vital signs monitoring and surgical site inspection. Psychosocial assessments include evaluating mental health, substance use, sleep patterns, social support, and functional status. Techniques like pain scales and medication adherence assessments are employed.

4. What are the five pertinent questions asked of the patient?

• The five questions address pain levels, alcohol consumption, sleep patterns, medication adherence, and changes in appetite, bowel movements, and energy levels since surgery.

5. What education is provided to the patient and caretakers?

• Patient and caretaker education covers pain management, alcohol consumption risks, sleep hygiene, medication adherence, and nutrition and hydration guidance.