Personal Profile
[Health History and Health Perception]
Student:……………………………… Date:………………
In-depth Assessment | ||||
Safe Environment (risks):
Patient at risk of infection in intraoperative stage due to a lymph node dissection for breast cancer in her right breast from under her right arm.
In postoperative stage patient at risk of infection due to the wound of the operation being liable to air and germs.
| Elimination (including incontinence):
Bowel Function: every 24 hours.
Bladder Function:
7-8 times daily , continued and urinary appearance is yellow .
Urinalysis:
Within normal limits . |
Pain: (use appropriate assessment tool)
Location:
Right arm and shoulder.
Severity:
Severe pain , it comes from swelling , and movements .
And she takes intravenous advil ibuprofen every 6 hours .
Aggravating factors: daily life sensation.
Frequency: before medication that is every 6 hours
Patient’s description: severe pain
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Skin: Skin is intact , red colour , warm. Wound Assessment (if applicable): Patient had a wound that had a long thin plastic drainage tube attached to a bottle in which fluid coming from the wound pours, it should have been removed after a week to ten days from the end of the operation , and she needed dressing change daily . | Level of orientation and neurological state: Patient is confused and depressed. She is suffering difficulties moving her right arm and shoulder, she has death fears and depression. She came on foot | |||
Diet: Antioxidants , with the adequate nutrients , vitamins , minerals, fruit , and vegetables .
Low fat protein.
Fluid intake is usually 6 glass of water daily .
Nutrition/Fluid/Metabolism:
She is obese class 1
Fluid intake is usually 6 glass of water daily .
Weight: 126 kg Height: 160 cm BMI:49
Blood Sugar (if appropriate) 11.8 in preoperative stage
| Communication:
patient at risk of mis communication due to depression and stress , patient can read and write Arabic and English .
she is preferred to communicate with Arabic nurses.
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In-Depth Assessment (continued) | ||||
Values-Beliefs-Culture:
she is Muslim and it is important for her to do the five daily prayers and Veils from foreigners .
Special Considerations:
The patient maintains a personal hygiene .
She does not eat sea food.
| Sleep-Rest:
patient sleep very well at night , she sleeps 8 hours almost daily and she takes some rest at afternoon .
she does not need any medication to help sleep .
| Coping and stress tolerance:
patient is coping well with her health condition , and she feels better gradually with therapy .
she does not have any difficulties at hospitalization period, and she like nurses and communicates kindly with them .
Perceptions of self and identity:
She is a teacher
patient has a large family that takes care for her responsibilities .
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Activity-exercise / mobility:
she is a teacher
in hospital she spends her time with her sister usually and talks a little.
she is doing some activities with Physical Therapy
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Family/carer perspectives and needs:
Her husband will take care if she need discharge . patient was with social worker services about one hour , she was cooperating and deal kindly with her , she is giving emotional support to patient.
The key people of the patient is her husband and sister , they are very good at coping with the least difficulty. She communicates with them through the phone. They make regular visits to her.
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Care Planning
Care Need / Problem / Potential Problem
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Goals of Care
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Nursing Actions
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Evidence-base for Actions
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Patient at risk of increased of pain and infection related to right lymph node dissection for breast cancer in her right breast from under her right arm.
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To prevent infection goal throughout hospitalization . To relieve pain and to present psychological therapy.
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Nurse must observe the temperature and colour every 4 hours.
Monitor for record signs of allergies
from or around wound and skin colour.
Report abnormal changes in temperature.
Use high hand hygiene techniques , or hand washing before and after patient care .
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Giving careful assessment to patient , monitor the signs and symptoms of high temperature, note the warmth of skin and assessing breathing by monitoring chest movements (Krag DN, Weaver DL, Alex JC, et al.)
Observe factors of causing infections such as white cells of blood. (Schmitz KH, Ahmed RL, Troxel AB, et al.: 2010)
Advising to use antiseptic solution , and teaching techniques of rubbing hands to maintain hygiene , having regular evaluation on patients hygiene techniques. (Miller SR, Mondry T, Reed JS, et al.1998)
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Care Planning
Care Need / Problem / Potential Problem
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Goals of Care
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Nursing Actions
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Evidence-base for Actions
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Encourage soy and beta-carotene foods or fluids , when indicated .
Encourage patient for being careful in moving and helping her walk and eat.
Provide adequate education for patient and members of family to learn about the infection symptoms such as fever , swelling , redness , hot , etc .
The persons who are liable to be infected should be banned from contact with patient. .
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Observing patient weight and giving advice concerning health food habits.
Observe food habits and ban bad eating habits. (rock CL, Doyle C, Demark-Wahnefried W, et al 2012)
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I confirm that the work presented relates to a person in this unit who the student has cared for and is the work of the student
Mentor:……………………………… Student:………………………………… …
Care Planning
Care Need / Problem / Potential Problem
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Goals of Care
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Nursing Actions
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Evidence-base for Actions
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Depression distress
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To help patients understand what depression is and how it is treated, this including antidepressants, and provided strategies for problem-solving to help patients overcome their feelings of sadness, upset and helplessness.
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Monitor patient's behaviour with others in clinic and record it daily.
Educate patient about the advances and progress she makes daily in weight and health generally.
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This is by detecting emotional distress to reduce psychological morbidity and collecting past information about the patients clinical experiences and if the curing climate was a financial stringency. (E.M.A. Bleiker et al.) .
Review and document the current dietary goals with the patient and family, assessment of fat and blood sugar. Improve food habits, advise doing exercises, reducing bad food habits as fat and sugar high consuming. Getting rid of some weight by following nutrients that are healthy .Giving some tranquilizers when needed. (Cimmino VM, Brown AC, Szocik JF, et al.2001)
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Care Planning
Care Need / Problem / Potential Problem
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Goals of Care
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Nursing Actions
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Evidence-base for Actions
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Observe and monitor the signs and symptoms of depression .
Measure depression levels .
Monitor and document patient's medication history , her understanding level and her submission .
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Observe depression symptoms and signs regularly to stop any suicide attempts if occurred.
Assessment of the patient involuntary symptoms such as straying, being anxious, having bad temper, being introvert, nervous and crying.
Assess voluntary signs such as poverty of speech, psychomotor retardation, poor social functioning) document the result and make evaluation for them.
Assess the patient information about her history of depression and how she deals with it and understand it. Document all necessary information in a file that is available when needed. (Prieto JM, Blanch J, Atala J, et al.2002)
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Considerable disability due to Chronic pain
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Identifying current sources of pain and help patient change life style in order to stop future pain problem.
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Monitor patient response to treatment.
Help using special techniques for letting patient get used to move her arm through simple easy exercises and give special sessions to train her.
Encourage the patient to co operate with the physiotherapy.
Checking fluid collecting around the wound if any.
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assess the patient condition through receiving treatment like Emla, her skin colour and her feel of pain and make assessment by questioning the patient about her feeling of pain and her comfortable positions.( Witt A, Yavuz D, Walchetseder C, et al.)
Help patient to get used to light exercises and focus on gentle contraction of muscles.
Teach the patient how to change bandages gently by wrapping the entire limb and make bandages tight around fingers and loose as patient move her arm.
Making sure that fluid around the wound move away by using a special massage called manual lymph drainage.
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I confirm that the work presented relates to a person in this unit who the student has cared for and is the work of the student
Care Need / Problem / Potential Problem
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Goals of Care
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Nursing Actions
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Evidence-base for Actions
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Provide healthy dietary that helps raise patients endurance.
Assist patient to use her arm easily with comfort and help eat and drink.
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Monitor patient's eating habits as she needs to be stronger and consider having adequate food for helping getting rid of obesity.
Provide help when needed to let patient use her arm in the way that does not cause pain. advise having special sponge baths instead of showers and provide help when needed. |
Care Planning
Care Need / Problem / Potential Problem
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Goals of Care
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Nursing Actions
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Evidence-base for Actions
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Patient at risk of having Hematoma
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Provide care to prevent having hematoma
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Provide guidelines to patient to use supportive brassiere.
Monitor patients skin closure in order to prevent having seroma.
Teach patients how to call nurses.
Educate the patient and family about how to help the patient and not let her do hard works.
Advise the patient about the necessary exercises to relieve pain and let muscles be in their best cases.
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Assessing patient movements of her arm and shoulder while using a special support brassierewill bolster efforts in order to sustain hemostasis. This can help relieving the tension on the patient skin caused by the weight of breasts as she is fat.
Assessing the skin condition regularly and measuring temperature in order to prevent hotness and redness of the skin.
Assess how the patient is comforted with nurses calling.
Give enough information for family about how to let the patient rest and do her exercises to avoid future pain and complications.
Guide the patient in doing the proper light exercises to have better muscles and reduces her weight.
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Evaluation
Date and Time
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Needs /
Problem No
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Comments
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Signature
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18 / 4/ 13 18 /4/13 10 /4/13 10/4/2013 |
1-Patient at risk of infection related to right lymph node dissection for breast cancer in her right breast from under her right arm.
2-Patient at risk of depression.
3-Patient at risk of
Chronic pain disability.
4-Patient at risk of hematoma.
| The risk of having infection decreased now due to monitoring patient's temperature, skin condition, food and hygiene habits and putting her in private room.
Patient psychological state is now improving very well due to psychological sessions with the psychologist's techniques of psychological therapy and the intensive nurse help and advice.
Patient now feeling comfortable due to light exercises and massage done with the use of Emla to relieve pain and due to the techniques and advice she learnt to use her arm and limb correctly.
The patient now is feeling very well and her skin is not red anymore , she is comfortable with the use of the support bra and the wound site is not swelling at all.
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I confirm that the work presented relates to a person in this unit who the student has cared for and is the work of the student
Mentor:……………………………… Student:………………………………… … Date: ………….
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