Mr Paul Stevens Case Study - Care Plan Presentation - Nursing Assignment Help

Assignment Task

Case Study 1 – Mr Paul Stevens
Paul is a 48 year old man who had an accident at work, resulting in a Traumatic Brain Injury (TBI). Paul has significant left sided weakness, severe dysphagia and dysphasia. He has been discharged from the acute setting to impatient rehabilitation for intensive therapy to help with his mobility, feeding and speech. Paul’s husband Gary is very supportive and has assumed primary caring responsibilities for their 8 year old daughter, Rosemary.
Paul and his family previously led a very active lifestyle that included regular outdoor activities such as hiking, horse riding and camping. Paul was in hospital for over 4 weeks prior to rehabilitation admission and is expected to spend a significant amount of time in rehabilitation to try and regain as much function as possible. Paul is currently unable to transfer himself and requires significant assistance with all ADL’s. Paul has tried using a 4 wheel walker in the hospital physiotherapy sessions but has not been successfully able to mobilise without significant support and assistance. Prior to the accident Paul was active with no significant medical history but does have a family history of bowel cancer, hypertension and cardiac issues. Paul is expected to be in rehabilitation for up to 8 weeks depending on his progress. Paul has not been able to express how he feels regarding his accident due to the dysphasia, but his partner Gary feels that he is not coping well with the possibility of significant long term changes to his lifestyle if he is not able to fully recover. Rosemary has been visiting Paul daily but is reluctant to stay for long because the hospital “smells funny”. You have just admitted Paul to the rehabilitation centre. You are his assigned primary nurse.

Case Study 2 – Ms Kylie Montgomery

Kylie is a 29 year old woman who was in a car accident and has sustained a severe burst fracture and spinal cord compression at T9. This has resulted in paraplegia below T9 and limited function and strength in her upper body. Kylie has been admitted for rehabilitation to learn how to manage her mobility and to function as independently as possible. Kylie’s injury has resulted in complete lack of function in her lower limbs as well as loss of bowel and bladder control. Kylie has limited family support, with her mother being her only living relative. Kylie and her mother have a difficult relationship and her mother has expressed a belief that Kylie will never be independent again, and that she will need to move home to be cared for. Kylie does not want to move home with her mother. Kylie is currently unable to manage transfers herself. She is wearing continence aids at present due to lack of bowel and bladder control. She is able to move herself around short distances with her wheelchair, but does struggle with other ADL’s due to tiredness. Kylie is not particularly good at being able to judge her limits in terms of energy expenditure. Kylie was moderately active with regular yoga sessions prior to the accident and works at a financial institution in the city. Her work have been helpful and are willing to modify her workplace for her when she returns. Kylie previously lived alone in an apartment that does not have disabled access. Kylie has a past history of anxiety and depression that was treated with medication and counselling. On admission to the unit, Kylie appears quite flat in her affect and does not seem to engage with you as her primary nurse. You have just admitted Kylie to the rehabilitation centre as her assigned primary nurse.

PART 1: CARE PLAN PRESENTATION
NOTE: References are expected throughout this paper using APA 7th reference guide
You are required to complete the PowerPoint template provided in relation to your chosen case study. The template is uploaded to Brightspace in the Assessment 2 folder. An example template is also provided for you. You will not be required to present this Powerpoint face-to-face, but you will need to upload it as Part 1 of Assessment 2.
In dot point form, you will need to:
-Identify the nursing diagnoses for your case study patient,
-Identify the nursing Interventions and justify your decisions using evidence based practice
-Identify other members of the Multi-Disciplinary Team who may be involved in the care of your case study patient

Please note the words already in the template are not included in the word count

PART 2: WRITTEN COMPONENT
NOTE: References are expected throughout this paper using APA7th Reference guide
Using the Case Study patient you have completed the nursing care plan presentation for, explore and critically analyse the goals, interventions and support needs and requirements for your patient in the rehabilitation and community setting.
-Critically analyse three key goals of rehabilitation that your case study patient wants to achieve at the completion of their inpatient journey. In doing so, consider
o The relationship between nursing care/interventions and the patients identified goals in the rehabilitation setting
o Collaboration within the multi-disciplinary team
o What support other team members will offer during rehabilitation

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