Nursing Case Study: Estelle's Plan Of Care

1024 Words 4 Pages
Estelle is the name of the patient at the facility she is located in room twenty-two. The patient is currently comatose and appears to have been in this state for the last three years. She has a good support system in place as her grandniece visits her on a daily basis. She is currently receiving music therapy on a weekly basis as part of her treatment plan (Lester, 1997)
Plan of Care When planning care for Estelle many aspects must be taken into consideration, such as the prevention of infection such as lung infections like pneumonia, the development of UTI due to having a Foley catheter in place, prevention of muscle wasting, and development of Deep vein thrombosis (DVT) (Arenella, 2014). The plan of care for Estelle would also include
…show more content…
1). The nurse will have a goal for the patient to remain pain free and for this she will have to assess for the need of pain relief through completing an assessment. The nurse will run into barriers in regard to the assessment of pain in a patient who is communication impaired, as the assessment of pain is usually a “subjective first-person experience” (Schnakers, et. al., 2010, 1) and the nurse will not be able to approach the patient and ask them if they are having any pain. The assessment of pain by the nurse will have to be comprehensive, perhaps integrating a pain assessment scale such as the DOLOPLUS 2, which can be used as a guide to determine if the patient is experiencing any pain this scale can be used in a long-term care patient (Schnakers, et. al., 2010). The nurse should pay close attention and recognize external signs that could potentially indicate that the patient is experiencing pain, such as fluctuation of vitals, tears in the patient’s eyes, facial grimacing, and posturing, these are some of the potential signs that the communication impaired patient can display and the nurse will include in her assessment of pain. As an intervention for pain the nurse will administer the prescribed analgesic “If any signs of discomfort occur, …show more content…
Estelle is unable to move and therefore increasing her risk of potentially acquiring pressure ulcers or skin tears. Although the compromise of skin integrity is not always inevitable in a patient who are undergoing palliative care (Matzo & Sherman, 2015) interventions must be set in place to prevent this issue. These may include having the nurse complete daily skin assessments to evaluate the integrity and intervene early if any signs are noted that could indicate a potential risk factor. Performing an assessment tool such as the Braden Scale to assist in identifying the patients risk (Matzo & Sherman, 2015) will be of importance. The nurse turning Estelle every two hours to alternate and shift weight on bony prominences will be an imperative intervention which reduces the risk of skin breakdown. The nurse can apply barrier creams as a shield to protect the patient’s skin (Arenella, 2014). The nurse can apply a prophylactic dressing to prevent an ulcer in the coccyx. Prevention is the key, but if a wound does develop treatment of the wound is not necessarily the goal of the nurse as the nurse must be the advocate for the patient in these circumstances and patient comfort supersedes the goal of treatment (Sherman & Matzo, 2015). The priority will be the maintenance of the wound, “such as wound odor, exudate, superficial critical colonization, and deep/surrounding

Related Documents