Nursing Care for Billie Orkins: A Person-Centered Approach

QUESTION

CASE STUDY:

PLEASE INCLUDE ALL REFERENCE USED

PLEASE consider which sub-standards of NMBA Registered Nurse Standards for Practice
apply to the case. This section will be written in an academic format, for example: intro,
body and conclusion.

Today is Monday 25 September 2023, you are a student nurse on your clinical placement at the
local community healthcare centre. The Registered Nurse has asked you to do a sample health
assessment on your next patient.
Billie Orkins
Date of birth:17/ 03 /1969
c/o 79 Walker Street, Maryborough
Mobile: 0412345678
Billie Orkins identifies as Aboriginal. Billie is here for a routine check-up and for their yearly flu
vaccine, despite not liking needles. Billie tells you they have been getting headaches, dizziness,
and fevers. Billie tells you that their heartbeat feels faster than normal.
Billie reports that they have been more thirsty than normal, but not eating as much, but they
are drinking a lot of soft drinks. Billie tells you they had runny poo three times already today.
Billie tells you that they have worked all over the country, in both underground and open-cut
mining. Billie also shares that they are finding it difficult to pick up more work since the
Capricorn copper mine was flooded in March.
Billie tells you that they have been feeling irritable and anxious about finding work and not living
in their own home and that they are staying with friends locally, while Billie’s own house is
rented out until January next year.
Upon checking Billie’s vital signs are as follows: Temperature 37.5; Pulse 105; Respiratory 16; BP
120/80; 02 Sat 98%. The GCS is 15; pain score 0/10, and today’s ECG is tachycardic yet a normal
sinus rhythm

QUESTIONS:

1. sample demonstration on how you will use therapeutic communication by listing three (3)
sentences that you would use in your communication with the patient.

2. Select subject or objective data to create two nursing diagnosis (actual / potential
issues) from the case study

3. Apply you two nursing diagnosis (either actual / potential issues) from the case study
to develop a person-centred care plan as below

4. Select the relevant substandard from NMBA Registered nursing standard for
practice. Discuss how you have met this substandard

5. Using the progress notes page and the observation graph chart, please document
the persons assessment and plan of care using SOAP framework.

ANSWER

Nursing Care for Billie Orkins: A Person-Centered Approach

Introduction

This case study revolves around Billie Orkins, an individual with diverse healthcare needs and a unique set of challenges. As a student nurse at the local community healthcare center, the application of therapeutic communication, nursing diagnoses, person-centered care planning, adherence to NMBA Registered Nurse Standards for Practice, and documentation through the SOAP framework play a pivotal role in ensuring Billie’s well-being.

Therapeutic Communication

Therapeutic communication is paramount to establishing rapport and trust with patients. When communicating with Billie, I would employ the following sentences:

“Billie, I’m here to listen and understand your concerns. Can you please tell me more about the headaches, dizziness, and fevers you’ve been experiencing?”
“I understand that needles can be challenging. How can I support you during the flu vaccine administration?”
“It seems like you’ve had quite a journey, working in different mining environments. Could you share more about your experiences and how they might relate to your health?”

Nursing Diagnoses

Nursing Diagnosis: Fluid and Electrolyte Imbalance related to increased thirst, decreased appetite, and frequent runny stools.
Nursing Diagnosis: Anxiety related to uncertain housing situation, employment concerns, and recent life changes.

Person-Centered Care Plan
Assessing

Fluid and Electrolyte Imbalance: Monitor Billie’s fluid intake and output. Assess electrolyte levels and laboratory results to identify imbalances.
Anxiety: Conduct a comprehensive psychosocial assessment to understand the extent of anxiety, stressors, and coping mechanisms.

Planning

Fluid and Electrolyte Imbalance: Collaborate with the healthcare team to provide intravenous fluids and oral rehydration solutions. Educate Billie on the importance of balanced fluid intake and offer dietary recommendations.
Anxiety: Develop a personalized plan to address anxiety, incorporating relaxation techniques, counseling, and referral to appropriate mental health services.

Implementation

Fluid and Electrolyte Imbalance: Administer prescribed fluids and monitor hydration status. Educate Billie on the importance of replacing electrolytes lost through diarrhea.
Anxiety: Provide active listening and emotional support during interactions. Introduce stress-reduction techniques, such as deep breathing exercises.

Evaluation

Fluid and Electrolyte Imbalance: Regularly assess fluid and electrolyte levels. Measure Billie’s response to interventions by monitoring symptoms like thirst and stool consistency.
Anxiety: Review Billie’s progress in managing anxiety through regular communication. Collaborate with Billie to determine the effectiveness of implemented strategies.

NMBA Registered Nurse Standards for Practice

The relevant substandard is “Collaborative and Therapeutic Practice.” By engaging in open communication, actively listening, and working collaboratively with Billie and the healthcare team, I ensure that holistic care is provided, taking into account Billie’s unique circumstances and needs.

Documentation through SOAP Framework

Subjective: Billie reports experiencing headaches, dizziness, fevers, increased thirst, and frequent runny stools. Expresses anxiety due to uncertain housing and employment.
Objective: Vital signs within normal range except for a tachycardic yet normal sinus rhythm. GCS 15; pain score 0/10; ECG findings consistent with tachycardia.
Assessment: Fluid and electrolyte imbalance, anxiety.
Plan: Administer intravenous fluids, educate on hydration, provide anxiety management techniques, refer to mental health services.

Conclusion

In the case of Billie Orkins, applying therapeutic communication, nursing diagnoses, person-centered care planning, adherence to NMBA Registered Nurse Standards for Practice, and documenting through the SOAP framework facilitate a comprehensive and individualized approach to care. By recognizing Billie’s unique background, health challenges, and personal preferences, I am committed to providing holistic and compassionate nursing care that promotes well-being and addresses both physical and emotional needs