Nursing Case Conceptualization Examples

Jessica`s nurse arrived at Igoe 7/1/15 she was introduced to Jessica at about 10:30am. Prior to her Jessica’s return home she was given a tour, a copy of medication, and an explanation of Jessica’s current behaviors. The nurse spent the day trying to get familiar with her. The nurse seemed overwhelmed with the behaviors exhibited by Jessica. Jessica spent the majority of the day with staff. Staff performed normal supports such as bathing, feeding, dressing, and food preparation laundry. Staff observed the nurse with Jessica as she engaged in behavior. The staff noted to supervisor that the assigned nurse was overwhelmed and staff then redirected her to the documentation. The nurse at lunch while Jessica was sitting in the sun and CCI staff
support Jessica by offering her water due to the high heat. Jessica consumed the water and sat outside for about thirty minutes. Staff did a body inspection on Jessica due to the heat and mosquito outside. No marks were found. After the staff finished her lunch she then observed staff while Jessica engaged in SIB. Staff discussed the things that cause Jessica discomfort or aggravation. Nurse assisted in support by using a pad to block Jessica’s head banging. The nurse then left for her first session stating that she would return for the evening.

The nurse returned for the evening at five.
Staff was assigned to the nurse to help assist the nurse. Jessica was still on her van ride. Staff expressed to her the importance of the van ride. Jessica arrived shortly after and Jessica is often offered her meal. Staff reviewed Jessica’s dietary needs with the nurse. Since this was the second time staff was offering Jessica a shake staff asked d the nurse to make it. The nurse was not comfortable and supported Jessica`s behaviors of head banging. Jessica went to her room and the nurse followed. CCI staff was assigned to demonstrate the current interactions with Jessica. Jessica is fairly independent and has her preferred activities. Jessica then came back down stair in desire to have her blanket. CCI staff was in ten feet of watching distance and observed the nurse`s interaction. The nurse used verbal direction. CCI staff then intervened to help translate Jessica communication style to the nurse. The nurse had noted that Jessica consumed a lot of cheese and it was not healthy. The staff then reviewed human rights and her current diet. Staff offered ways to offer her foods she likes and the food she is prescribed. The nurse prepared a meal that included bacon and eggs. Jessica did eat some of her meal but through it up. Staff suggested that the nurse make her food in smaller portions. After her meal Jessica wanted to get in her bath. Jessica started to run her shower. CCI staff went to ensure her safety due to the floor being
slippery from previous baths. Jessica runs her own bath and is able to get in and out with very little support. The nurse stayed with Jessica in the bed while CCI attended to other individudlas. Staff over heard the nurses attempted to communicate with Jessica her bath was over. The conversation resulted in her in Jessica screams of aggravation. Staff was present at the bottom of the steps for this. Shortly after staff noted the sound of Jessica getting out of the tub. Staff went upstairs to see the nurse supporting her out the tube. CCI staff then went to the room to properly dress Jessica. Through out the rest of the evening Jessica sat in the living room with her peers while the nurse completed her documentation. Jessica was engaged with her peers and her prefer activities. Staff checked in with the nurse to offer assistance. The nurse said there were no problems or concerns. Staff discussd again, the importance of knowing how to communicate with Jessica. The nurse completed her documentation and had staff sign it. No incidents had occurred.