NCLFNP - Mr. Robert McClelland Case

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. Mrs. McClelland states, "He
has just gotten too weak 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. B?
Admission assessment is an essential part of the nursing process, this provides us with the
vital information related to Mr. B’s health condition. It is basically a baseline for a
successful care plan to be provided. This helps us to recognize current and future patient
care needs and identify appropriate interventions.
2. Describe the four features of assessment and why they are critical to ensuring positive
outcomes within the context of interdisciplinary care for Mr. B.?
The physiological, psychological, sociological, and spiritual needs of our patient, Mr.
B, would effectively determine a diagnosis and treatment. The Physiological
aspect deals with the patient’s physical health condition. This represents Mr.
B’s dimension of total well-being, this is essential since it shows the state of
his physical body and how well it's operating. Psychological deals with the patient's
mental and behavioral processes in health. Stress, control and perceived control is
important in patient’s cooperation in health care. Sociological is a determinant of
the patient’s health as social factors are crucial in the patient’s environment. It is a
key in making Mr. B. feel positive. Spiritual on the other hand, is extent that
it is seen as key aspects of health. Patient’s seek and express meaning and purpose
and the way they experience connectedness.
3. Describe how assessment is essential to the other steps of the nursing process.
Assessment is a fundamental component in the nursing process, assessing

determines the patients' health problems and caring needs. Therefore, this serves an
important role in designing and implementing the nursing care plan and
intervention. Thorough and accurate assessment is important since this is a baseline
of the process.
4. Identify all primary and secondary sources of information that you could use to help gather
information about this patient. Differentiate the types of data that can be elicited from these
sources.
Primary data can only be obtained from the patient himself while secondary are
from second-hand account of a family or witness.
Primary sources and data: Mr. Robert B., 81-year-old, diagnosis of pneumonia
failure
Secondary sources and data: The wife stating, "He has just gotten too weak 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."
5. How will the observation of Mr. B. during the initial assessment contribute to the patient’s
database?
Mr. B’s observation is an essential data to confirm and clarify issues regarding his
condition. This can serve as a data that could adequately recognize and link his
needs, thus will be included in the patient’s care for planning.
6. Describe in simple terms the four techniques of examination and the type of information you
can elicit from the patient pertinent to this patient’s present state of health.
The four techniques include Inspection, Palpation, Percussion, and Auscultation.

Inspecting is basically careful and close observation of the patient as a whole, taking
notes of seen cues. Palpation involves touching the patient with variant pressure,
this could help gather indication with abnormality in the patients organs, texture,
moisture, elasticity, pulsations, masses and temperature. Percussion uses the fingers
to tap to the patient’s body which locate organ borders, identify organ shape and
position, and determine if an organ is solid or filled with fluid or gas. Lastly,
auscultation involves listening for various lung, heart, and bowel sounds with a
stethoscope. This examines the circulatory and respiratory systems, as well as the
alimentary canal.
7. Discuss how you will prepare yourself, Mr. and Mrs. McClelland, and the environment to
enhance the data gathering inherent to a health history.
Providing privacy is important for the patient’s environment, we should also make
sure they are comfortable and is able to freely speak, without distraction. Taking in
mind about their background to avoid miscommunication and offend on their part.
Questions should be well thought of considering their beliefs and values.
8. For each of the following sections of the health history, create a closed question and an open
question, to elicit data about that area specific to this patient.
HISTORY SECTION CLOSED QUESTION OPEN QUESTION

Reason for seeking When did it begin? Tell me about your health
healthcare problems.
History of present illness Do you have any present What present illness do
health issues? you have and how does it
affect you.
Patient’s perception of Is there pain in particular Describe the pain and
health status & part of your body? how you feel.
expectations for care
Past health history Did you have any surgery What surgeries have been
or procedure regarding performed on you and
this past illness? how was your recovery?
Family health history Is someone in your familyTell me what similarities
die or have underlying and/or differences you
condition like yours? noticed between your
condition?
Social health history Do you have any How does this help you
community support? and influence your
health?
Medication history Have you been taking any What medicines are you
medicines? taking?
Complementary/ Have your tried any Tell me the effects of this
alternative modalities alternative medication? on your health.
9. What is one conclusion you can make regarding this information?
Mr. B and Mrs. B’s perception on the amount of food Mr. B should consume
contradicts. Mrs B. think her husband should eat more while Mr. B disagree and
defends he is eating what he think is right for him. This raises an issue on the socio and
behavioral aspect of the patient.
10. How can you validate your conclusion about this information? Consider both the primary and
secondary sources of data in this situation.
Mr B’s opinion serves as our primary data but to validate this, we should ask more
specific and adequate questions to prove his claims. We could also note his wife’s
statement since this is a secondary data. With careful observation of Mr. B’s eating
habits we could assess what the facts are.
11. Discuss the implications of failing to validate your conclusion regarding these data on the
nursing plan of care.
It is important that we record the truth about the patient, validating data helps us
assure a consistent care plan. A mistake could definitely make huge changes to our
intervention and the client’s health as well. The conclusion is intended to help the in the
care plan but if its wrong this could effect differently and not help in the patient’s
development.

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Mr.

1. Why is your admission assessment foundational to the care of Mr. B?

Assessment is a fundamental component in the nursing process, assessing

The four techniques include Inspection, Palpation, Percussion, and Auscultation.

HISTORY SECTION CLOSED QUESTION OPEN QUESTION

9. What is one conclusion you can make regarding this information?

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