Rhonda Silverman Nursing Care Plan

Nursing Care Plan for Rhonda Silverman (pseudonym)

Introduction

Rhonda Silverman is a 89 year old female who is currently residing in a rest home. She formerly worked as a short hand typist prior to her marriage after which she had 3 children and was actively involved in volunteer work within her community while her children were being raised. Rhonda has had a very active life and loves to travel. She has visited North America, Europe, Asia and Oceania. As she has aged her health as deteriorated and Rhonda can no longer travel and or be a volunteer.

Recently since her health is worsening and she has become a high risk, this has impacted her activities of daily living as a severe fall has led to her admission. Ronda require assistance with
basic cares including showering, toileting and basic mobility.

Prior to her admission Rhonda was living alone as her husband was no longer around, however one son visited often and assisted with anything she needed at home, but after her fall she was admitted.
She did not initially like being put in the facility as she felt as if she had no freedom and was trapped because she required assistance with many tasks. However since she has settled, Rhonda has bonded with other members and is compliant and actively participates in activities.

The process below outlines how the information and consent was gained to put this nursing care plan together.
1. Spoke with the RN in charge to ensure that it was ok to interview a resident for the assignment.
2. Obtained consent from Rhonda to do the interview and viewed the notes documented by caregivers to get some external information to avoid excessive questions for the resident.
3. Conducted the interview with Rhonda, during which data was gathered, that followed Gordon's Functional Health patterns.
4. The collected health data was summarised and reviewed so that a nursing diagnosis can be developed.
5. Interventions and goals were developed to help Rhonda.
6. The finished process was evaluated and a finalised copy was offered to
Rhonda.

Assessment

Activity - Exercise Pattern

Rhonda's hygiene is fair as she gets a shower every second day and her dentures get cleaned twice daily which she is encouraged to do herself.
She eats lunch and dinner in the main dining room with the other rest home residents, but breakfast is eaten in her room every morning. In her lower left leg she has weakness that prominent in and around the knee and often it is felt in her other leg and her feet due to her osteoarthritis. She also feels stiffness in both knees and lower legs, and it is light in her hands and hips. These weakness have effected have stopped her from being able to drive, participate in club activities or her volunteer work or play the piano. Apart from this she is able to partake in some of her old hobbies and has discovered new ones. These include reading, puzzles, watching TV, going to church and participating in activities in the rest home, however, some things like indoor bowls and piano she can no longer do. Within Rhonda's daily routine she does regular strengthening exercises twice daily on her own or more often if other residents are doing them
also.

Rhonda has bonded with many of the other residents in the rest home section of the facility. This means she tends to get involved in group activities and exercises however her limited mobility often upsets her as she requires assistance to do simple self-care and bathing.

Actual Diagnosis:
Lack of self-care/bathing related to limited mobility and pain from osteoarthritis manifested by inability to do self-care and bathing activities.

Risk for falls related to limited mobility, limb weakness and history of falls prior to admission

Value - Belief pattern

Rhonda is quite a religious person. She was raised since she was young as a Presbyterian and went to church regularly until she got married. When she married he husband she then went to a Methodist church with him for a while until she then returned to her Presbyterian church. In her life she has no current goals because Rhonda believes that she has achieved all she set out to do. She has a strong relationship with god and does have an accurate belief in the afterlife. Her afterlife beliefs revolved around that she believes that she will be going to heaven and that people who are unhappy in life feel that way because they are unsure where they will be going in the afterlife. Since being admitted to the rest home she is aware she has lost her sense of hope in her god and the religion.

To Rhonda religion is a big part of her life. She has strong beliefs in god and has attended church all her life because it is important to her. Recently since her pain has been getting worse and she no longer wants to live, she is losing hope in god.

Actual Diagnosis:
Losing hope in religion related to not being able to be an active member of her church community and chronic pain. As evidence by her still living in her pain and not have been "taken" to heaven.

Risk for spiritual distress by questioning meaning of her suffering as evidence by loss of hope and anger toward god.