The consent should be obtained from the carer about the medical intervention proposed. The nursing care should include, Specific communication, Drugs and nutritional plan, Investigation plan, Psychological and emotional requirements and Physical and rehabilitation requirement. The principles of the Mental Capacity Act 2005: Every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise. A person must be given all practicable help before anyone treats them as not being able to make their own decisions.
Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision. Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests. Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms (legislation. gov. uk, 2005). Assessment Assessment requires good communication skill. It is the right of patient and carer in need. This can be analysed using Assessment Tools and the ability to observe and document Physical, Social and Psychological changes.
Tract and trigger system is a useful tool in assessment. Track and trigger systems rely on periodic measurement of observations (tracking) of patient, with predetermined action care till certain thresholds are reached (triggering). Care plan: primary requirement include recording patient’s details in the case sheet. The patient’s name, sex and age are recorded first. Recording, past history prior to post operative care and events, give valuable input in assessing the nursing and medical care requirements. Patient’s details: Name of patient: Jean Sex: Female Age: 42 years Patient’s history: 1.
Medical history prior to admission to A&E: Down’s syndrome, hypertension, uncontrolled type2 diabetes mellitus, hypercholesterolemia 2. Subsequent history after admission: Myocardial infarction diagnosed; immediate traditional Cardiac Artery Bypass Grafting done using Heart-Lung Bypass Machine which keeps blood and oxygen circulating the body; heart was stopped for one hour using medicine; which allows surgeon to operate on still heart. Heart Function restored after surgery. Present admission: Present medical status: Post-operative care after CABG after admission to A&E ward for chest tightness and shortness of breath. Significant events: Event Observed: First day: nil Second day: Oliguria, elevated creatinine Diagnosis: Acute Kidney Injury Probable cause: hypotension, diabetes, cardiac surgery, radio contrast dye Medical intervention during next 24 hrs: Monitoring (LO 1 & 4) and Nursing Care (LO 2 & 3).
Begin, L. (2013). The Nursing Students Practical Guide to Writing Care Plans . www.scribd.com/.../The-Nursing-Student’s-Practical-Guide-to-Writing-C....
BootsWebMed. (2014). Anaemia, vitamin B12 or folate deficiency - Introduction. Retrieved May 1, 2014, from Boots Web Med : http://www.webmd.boots.com/a-to-z-guides/tc/anaemia-vitamin-b12-or-folate-deficiency-introduction
Carney, E. (2013). Acute kidney injury: High-potency statin therapy and risk of acute kidney injury. Nat Rev Nephrol , 9 (6), 309.
cmft.nhs.uk. Nursing Process . www.cmft.nhs.uk/.../Assessingplanningimplementingandevaluatingcare_.
Davenport, A., & Tolwani, A. (2009). Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit. CKJ Clinical Kidney Journal , 2 (6), 439-447.
Davey, P. (2011).
HSE. (n.d.). Anaemia, iron deficiency. Retrieved May 2, 2014, from HSE: http://www.nehb.ie/eng/health/az/A/Anaemia,-iron-deficiency/Symptoms-of-iron-deficiency-anaemia.html
Kidney-cares.org. (2012). Itchy Skin and Kidney Function. Retrieved May 1, 2014, from Kidney Cares Community : http://www.kidney-cares.org/kidney-failure-symptoms-complications/223.html
knowsleyccg.nhs.uk. (2014). Anaemia, vitamin B12 or folate deficiency . Retrieved May 1, 2014, from knowsleyccg.nhs.uk: http://www.knowsleyccg.nhs.uk/health-a-to-z/a/anaemia-vitamin-b12-or-folate-deficiency/
Leach, M. (2014). Interpretation of the full blood count in systemic disease – a guide for the physician. Journal of Royal College of Physicians of Edinburg , 44 (1), 36-41.
legislation.gov.uk. (2005). Mental Capacity Act . http://www.legislation.gov.uk/ukpga/2005/9/contents.
Lewington, A., & Kanagasundaram, S. (2011). Acute Kidney Injury Practice Guidelines . http://www.renal.org/guidelines/modules/acute-kidney-injury#sthash.EiJQnCwr.dpbs.
Marsh, C., & Brown, J. (2012). Perioperative fluid therapy. Anaesthesia & intensive care medicine , 13 (12), 594-597.
McGrawHill. (n.d.). Introduction to the care planning process. www.mcgraw-hill.co.uk/openup/chapters/9780335237326.pdf.
NHSDirectWales. (2014). Anaemia, vitamin B12 and folate deficiency. Retrieved May 1, 2014, from NHS Direct Wales : http://www.nhsdirect.wales.nhs.uk/encyclopaedia/ch/article/anaemia,vitaminb12andfolatedeficiency/?print=1
NICE. (2002). Principles for Best Practice in Clinical Auidt. Oxon, UK: Redcliffe Medical Press.
Rahman, M., Shad, F., & Smith, M. (2012). Acute kidney injury: a guide to diagnosis and management. Am Fam Physician , 86 (7), 631-9.