Nursing and Mrs Green

3252 words 14 pages
1 Case Study Mrs Green (20 marks for general description)

Mrs. Green is a 55 year old female who had a total knee arthoplasty 3 days ago. The client is on 6 hourly observations. The last set of observation are: Temp 36.5 C, RR 22, HR 110, BP 170/86mmHg and SpO2 98% on room air. She has been complaining of ‘awful pain’ in her knee.

She has refused to have a shower and do her routine ROM exercises due to the pain in her knee. She requires assistance to perform ADLs at this stage and expresses feelings of embarrassment and frustration. Mrs. Green has also reported that she has not opened her bowels since the operation.

Socioeconomic status: Mrs. Green lives with a husband and has three grown up children.

1. Write a nursing care plan
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He appears clean and tidy but lethargic. He does not interact much with the nursing staff unless it is necessary.

Socioeconomic status: He works as a chef in a popular restaurant in the town and works very long hours, 6 days a week. His wife is very caring and supportive with his diagnosis, but becomes emotional when she sees babies in public.
1. Write a nursing care plan for Martin:
Provide two (2) actual and two potential nursing diagnoses include interventions and expected outcomes for each. Use the template provided.

Please see attached

2. Write nursing admission notes for Martin. Use the Progress Notes template provided.

Please see attached

3. Describe the appropriate method to collect health related data as a part of the admission process for Martin.
A patient interview will need to be conducted on Martins hospital admission. The nurse will need to get to interview Martin to obtain a complete medical history, his vital signs, blood pressure, temperature, oxygen saturation, pulse and respiratory rate, these can be completed at the bed side with Martins permission and need to be documented appropriately (Koutoukidis, Stainton & Hughson 2013, p.274).
The method that the nurse can use is SOAPIE or ADPIE this will have subjective and objective data along with assessment, plan and implementation both methods can provide the an accurate indication of the best health care plan for Martin (Koutoukidis, Stainton & Hughson

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