Sample Nursing Assessment

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Nursing Assessment Deakin District Nursing Service visited Mrs Janet Smith on June 16th2008; this was to undertake the first nursing assessment within the client’s home environment. Throughout this visit with Mrs Smith, it was noted that she lives with her partner Mike and their children. Currently the children are staying with grandparents whilst Mrs Smith is unwell. Mrs Smiths partner states he does not believe Janet requires home nursing and would like to be left alone to manage. It is also noted the family home which is situated in Melbourne’s Outer East, the garden is poorly kept with cracks and holes in the concrete path leading to the front door. The front door is difficult to open. Upon entry into the master bedroom, where…show more content…
Mrs Smith assures me, ’the dog is fine with strangers.’ During the initial assessment, it was found that Mrs Smith has been resting and elevating her legs. Pain management has been controlled whilst in hospital. Mrs Smiths IV site appears dry and clean, IV was replaced on June 15th 2008, resited to the clients left forearm. Assessment During the nursing assessment the following was cited: Both IV bags of Sodium Chloride 0.9% have been opened, as it appears to have a spigot of some kind attached to the opening. Potential risk of compromised infection control, due to the animals roaming the house and jumping up onto the bed. Animals within the client’s home consist of one large dog and two cats. All three animals jump onto Master bed with the client. Clusters of animal hair cited on the carpet in Master bedroom. One bird in unkempt birdcage located in bedroom. Large dog sits on the bed on top of the bluey mats, compromises clean field. Client also has cigarettes, matches and ashtray on bedside…show more content…
Rationale to reduce infection control issues within client’s home environment. Potential fire hazard related to smoking cigarettes in the bed. Rationale to educate the client to reduce smoking within the bedroom. Social Determinants of health pose many factors with the current client. There are many areas, which affect the health equity of Mrs Smith, with support it leads to better health. Social support – Mrs Smith and her partner Mike need to engage and receive social support from other family members and the community (nursing, healthcare, social worker) Stress – both Mrs Smith and Mike will feel high anxiety and stress and may have a lack of control over living and work circumstances. This may lead to more mental and physical health. Work – Mike is caring for Mrs Smith and currently refusing home services, his employment opportunities may suffer as a consequence. As health carers we need to ensure Mike and Mrs Smith are educated in understanding the importance and the health care support that is available. This will ensure health

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