Mrs. Anderson, an 85-year-old widow, presents with complaints of falling into her chair at home, dribbling when trying to get to the bathroom, fatigue, and loss of appetite for the past week

QUESTION

Mrs. Anderson, age 85 years. She complained of falling into her chair at home, dribbling when trying to get to the bathroom, being tired, and not being hungry for 1 week. The primary care provider evaluated a urinalysis and complete blood count (CBC) with differential and recommended admission to rule out sepsis and urinary tract infection. Mrs. Anderson also has a fungal infection within her mouth. Mrs. Anderson is a widow of 3 years, was married for 62 years, has three adult children, and lives in her own home with an unmarried son. She has a history of two incidents of CHF 4 years ago, a hysterectomy 22 years ago, an left knee replacement 15 years ago, and situational depression when her husband passed away. VS: BP: 140/88 mmHg, P: 90 beats/minute, RR: 22 breaths/minute, T: 35.7°C. The nurse starts her assessment.

1. Part 1 -Introduction of plan of care scenario and expansion of details to enrich scenario (20%)
2. Part 2 – Using communication theory and applying course concepts, including the College of Nursing of Ontario (CNO) standards of practice and guidelines to examine plan of care concerns(20%)
3. Part 3 -Demonstration of communication framework such as SBAR, ISBAR or IPASS to summarize the plan of care or concern of the patient (20%)

ANSWER

Part 1 – Introduction of Plan of Care Scenario and Expansion of Details

Mrs. Anderson, an 85-year-old widow, presents with complaints of falling into her chair at home, dribbling when trying to get to the bathroom, fatigue, and loss of appetite for the past week. Her primary care provider ordered a urinalysis and complete blood count (CBC) with differential and recommended admission to rule out sepsis and urinary tract infection. Additionally, Mrs. Anderson is coping with a fungal infection within her mouth. She lives in her own home with an unmarried son and has a history of two incidents of congestive heart failure (CHF) four years ago, a hysterectomy 22 years ago, and a left knee replacement 15 years ago. Following the passing of her husband three years ago, she experienced situational depression.

Mrs. Anderson’s vital signs upon assessment are as follows: blood pressure (BP) 140/88 mmHg, pulse rate (P) 90 beats/minute, respiratory rate (RR) 22 breaths/minute, and temperature (T) 35.7°C. The nurse has initiated her assessment to gain a comprehensive understanding of Mrs. Anderson’s health status and address her presenting concerns.

Part 2 – Applying Communication Theory and Course Concepts to Examine Plan of Care Concerns

In examining Mrs. Anderson’s plan of care, effective communication is paramount to ensure patient safety and quality care. Communication theory emphasizes the exchange of information between healthcare professionals to facilitate coordinated and patient-centered care. The College of Nursing of Ontario (CNO) standards of practice and guidelines advocate for clear and accurate communication, which is crucial in Mrs. Anderson’s complex case.

Given her age and multiple health issues, Mrs. Anderson is at increased risk for sepsis and urinary tract infection. Timely and accurate communication between the primary care provider, nursing staff, and other healthcare team members is essential to prevent potential complications and provide appropriate interventions promptly. Using a collaborative approach, the healthcare team can share relevant information, such as lab results and vital signs, to guide decision-making and develop an effective plan of care tailored to Mrs. Anderson’s needs.

Furthermore, considering Mrs. Anderson’s history of depression and recent loss of her spouse, emotional support and therapeutic communication are critical elements of her care plan. Active listening and empathy can help address her emotional well-being, allowing the healthcare team to assess her mental health status and provide appropriate resources or referrals as needed.

Part 3 – Demonstration of Communication Framework (SBAR) to Summarize the Plan of Care

SBAR (Situation, Background, Assessment, Recommendation) is a structured communication framework that fosters clear and concise information exchange. Utilizing SBAR, the nurse summarizes the plan of care and concerns for Mrs. Anderson as follows:

Situation: Mrs. Anderson, an 85-year-old widow with a history of CHF, presents with recent falls, urinary symptoms, fatigue, and loss of appetite. The primary care provider ordered urinalysis and CBC with differential, suspecting sepsis and urinary tract infection.

Background: Mrs. Anderson has a history of CHF, a hysterectomy, and a knee replacement. She also experienced situational depression following her husband’s passing. She lives with her unmarried son, and her vital signs indicate mild hypertension.

Assessment: Further assessment reveals a fungal infection within her mouth, and she appears fatigued and disinterested in eating. Emotional support is vital, given her recent loss and history of depression.

Recommendation: Collaborative communication between the healthcare team members is essential to address Mrs. Anderson’s presenting concerns, rule out infection, and provide appropriate interventions promptly. Additionally, therapeutic communication and emotional support should be incorporated into her care plan to address her emotional well-being.

Conclusion

Mrs. Anderson’s plan of care requires effective communication and collaborative efforts to ensure patient safety and tailored interventions. By adhering to communication theories, CNO standards, and utilizing frameworks like SBAR, the healthcare team can provide comprehensive care that addresses Mrs. Anderson’s physical and emotional needs. Through these efforts, Mrs. Anderson’s well-being can be optimized, and her complex health issues can be managed effectively.