Nursing Process Case Study: Assessment
Please draw you Care Plan from this information/Case Study must be complete (due for
class 10/2) and will be graded. The Care plan will be for class discussion.
Assessment is the
...
Nursing Process Case Study: Assessment
Please draw you Care Plan from this information/Case Study must be complete (due for
class 10/2) and will be graded. The Care plan will be for class discussion.
Assessment is the first step of the nursing process and it provides the data that allow the nurse to
help the patient. It is a systematic gathering of information related to the physical, mental,
spiritual, socioeconomic, and cultural status of the individual. Let’s look at a patient situation
common in the healthcare system.
■ Mr. Robert McClelland, an 81-year-old, is a new admission from the local hospital to your
long-term care facility. After Mr. McClelland’s last bout with pneumonia and congestive heart
failure, his wife of 59 years has decided she is no longer able to care for him at home. He has
been experiencing some respiratory distress which requires oxygen. Upon this admission his O2
SAT is 93, and respirations are 22. Mrs. McClelland states, “He has just gotten too weak, rarely
walks, and can’t help me care for him. I am so afraid he will fall and hurt himself. I am so worn
out trying to care for him myself. I have to bathe him and remind him to eat; sometimes I’ve had
to feed him myself or he won’t eat. He can be so forgetful. I hope I am making the right decision
for him, because he never wanted to go into a nursing home.”
1. Why is your admission assessment foundational to the care of Mr. McClelland?
The admission assessment is foundational to Mr. McClelland’s care as it is the first step in the
nursing process and allows for the nurse to systematically gather important information related to
the patient’s current physiological, psychological, sociocultural, developmental, and spiritual
status and needs. An assessment of the patient’s care needs based on his/her perception of the
illness is essential for high quality nursing care as it provides information about the complexity
of the patient’s health situation. Furthermore, the admission assessment allows for nurses to
establish a baseline of health for the patient by creating a patient database, so that individualized
interventions may be carried out and monitored effectively. Finally, the admission assessment
also allows nurses to establish a comfortable and trusting rapport with the patient, and further
allows the nurse to make selective intellectual judgments regarding the patient’s health and
develop an effective plan of care.
[Show More]
