Introduction

There are two steps health care professionals follow to collect information from the client, which is subjective and objective data. It is a vital responsibility to identify assessments that could be used to assist in the planning and implementation process of the client. The Gordon assessment is a good  method of data collection concisely and accurately (Gordon 2014).The focused assessment  plays vital role in assessing the condition of the client according to high, medium and low risk. Patient centered nursing care is an important aspect of nursing intervention. Including the patient’s family and other health care professionals in the patient’s care plan can help in achieving better patient outcome. This essay is aimed at identifying the nursing care plan and intervention using two focused assessment tools and include the results of these assessments in the clinical assessment.

Bio data of client

The client name is client XX and he is 70 years old. He presented with osteoarthritis cervical spine and multiple sclerosis. He commenced on medicines such as paracetamol 1 gram PRN. He states about his limitations due to lower limb immobility and low sensations in both feet. He understands his health condition improved, because now his condition enhanced and he is able to walk with a walking frame with the supervision of assistant. He reported neck pain due to osteoarthritis cervical spine, but after the painkiller he relieved from neck pain.

Gordon Assessment

Health perception

The patient XX states

His health condition improved after hospitalization. 

He understands his health condition because he presented with lower limb sensation and decreased mobility.

The patient’s vital signs are stable, no variation in it (Gordon 2014). 

Nutritional-metabolic pattern

The patient XX states

The patient XX is on his full diet and he prefers to eat large meals in his diet plan, he has a good appetite.

He eats healthy food with green leafy vegetables, fruits, and sandwiches. 

He also likes a variety of other foods such as fish curry, mixed vegetable and cheese curries in his diet.

He drinks 1-liter fluids every day, he is on free fluids. He likes hospital diet because he said it is full of nutrients and according to his requirements. 

He has no food allergies. He has no eating problems, he can easily eat and chew food. His teeth in good condition.  

His BMI is 23.5 (Healthy Weight). His height is 180 centimeters and his weight is 76 kilograms. He looks hydrated because he takes plenty of fluids daily.

Elimination pattern

Bowel

The patient XX states

His elimination pattern is good. It is normally continent, but he reported recently constipated. He has taken some laxatives to pass stool easily.

His bowel quality is frequently typed 4  Bristols (Continence Foundation of Australia, 2018, p. 1).

Bladder

The patient XX states

He is not experiencing any problems in passing urine. 

Urine tests show no sign of infection. His urine color is light yellow.

Skin conditions

The patient XX states 

His skin is intact and moisture in texture.

The skin assessment show patient XX has intact skin and his skin is moisturized with no bruises, lesions, and a scar on his skin. 

Activity-exercise pattern

The patient XX states 

He has difficulty in walking and feels low sensation in both feet.

Thus, his condition has improved and he can walk with a walking frame more than 20 meters independently (Hedstrom, Olsson & Alfredsson 2015, p 87).

He has a high risk of falls and injuries due to the low sensitivity of the lower limb and decreased mobility. (Hendricks)

He needs an assistant in personal cares; I assisted in the lower body part for washing and dressing up.

He has bed mobility and he can sit and stand with help of bed sided handle.

Sleep-rest patterns

The patient XX states

He has difficulty in sleeping due to osteoarthritis cervical spine.; his pain score was 7 out of 10 (Williams & Wilkins, 2010, p. 460). He commenced on painkiller paracetamol PRN (if needed) and after having it, he feels relieved from pain.

He usually sleeps 7 to 8 hours a day. He also uses a neck pillow at night for comfort and relief from pain. 

Health team provided him with health education to induce his sleeping pattern.

Cognitive-perceptual pattern

The patient XX states

He is wearing glasses, he cannot read small print without glasses.

His hearing is good, he responded well to conversations.

He complained about vertigo in the past, recently he has no signs of dizziness. 

He can speak clearly, he is oriented to place, date and time. His memory is very good because he shared his past memories with me. 

He has knowledge about his disease condition and its effects on his health due to pain and immobility.

Self-perception-self-concept pattern

The patient XX states

His perception, body image, identity, and self-esteem were good.

His posture was imbalanced due to decreased sensation in lower limbs. 

He makes good eye contact while talking and his voice has clarity.

Role-relationship pattern

The patient XX states

He has a good family and social relationship.

He is a good father and friend.

He is satisfied with his family, work and his social relationships.

Sexuality-reproductive pattern

The patient XX states

He lives with his wife and has two children.

He lives happily in a relationship. He has a loving and supportive family to take care of him. 

Coping Stress tolerance pattern

The patient XX states 

When he feels stressed he has general coping strategies to cope up with the stresses. 

He usually reads books, listens to music and socializing with friends to reduce his stress and burden.

Value beliefs pattern

The patient XX states 

Subsequently, his beliefs are a good role model for his family.

He feels he gave equal values to his family and his friends.

He has a belief in spirituality and respect other religions and cultures also. 

He has some knowledge about other cultures and he reads religious and history books to gain more knowledge and calm his mind.

Focused Assessment

Accurate assessment and consideration of the patient's main complaint or question, which requires clinical judgment, are known as focused nursing assessments (Lichtner et al. 2016, p 27). It may include at least one body system. In the present case, the client is an adult who has presented with the chief complaint of pain in neck and increased risk of falls associated with osteoarthritis of the cervical spine and multiple sclerosis. Focused assessment should include a thorough evaluation of the patient's pain score, as well as an assessment of the risk of falling.

Pain scale

Patient XX has pain in neck due to osteoarthritis of the cervical spine and it is relieves with analgesics, for example paracetamol. Also, he has difficulty in sleeping due to osteoarthritis of the cervical spine; his pain score is 7 out of 10. He uses a neck pillow to reduce his pain in the neck.

The assessment of pain is crucial if the treatment is to be effective. Health care professionals such as nurses are in a unique position to investigate the cause of pain because they have the greatest contact with the patient and his family at the hospital. Agony is multidimensional, so assessment must include intensity, area, time and portrait, effect on movement. Now and again, it is difficult to differentiate agony, anxiety and pain (Lichtner et al. 2016, p 27).

While evaluating the patient's assessment of pain scale, it focuses on including the history of pain, the area of agony, the intensity of pain, intellectual development, and the understanding of pain. The importance of using the same digital rating (0-10) is that the number identifies with a similar pain scale in each apparatus.

Risk assessment of fall (Hendrich II risk model)

Client XX is a 70-years-old sound male, and was hospitalized for worsening of osteoarthritis and multiple sclerosis. Insufficient control of pain has delayed his recovery. The moment he goes to climb to the side of the bed or seat, he should rise up with both hands. When he does the first few steps, he seems insecure, walking with some difficulty and tries to take support from surrounding objects.

When the nurses staff enquires him about helping him while using washroom, he communicates with a strong desire to "go alone and remain independent". He believes that the craving for autonomy can make him not want or sit down for help when he needs it. The nurse should examine the patient’s surroundings for factors that could increase the risk of falling but realizes that if his danger is high, other intercessions would be expected to be reduced (McKechnie, Pryor & Fisher 2016, p 38). To determine the level of danger, the nurse staff can uses the Hendrich II risk model. 

The Hendrich II-type risk reduction risk model was created by nurses to assess the risk that the patient would fall into the full range of considerations. It makes it possible to predict which patients are in danger of collapse. Its purpose is to target rapidly and identify the risk factors recognized as disorder, confusion, impulsiveness, depression, modified elimination, unsteadiness, dizziness, male sex, taking antiepileptic medications or benzodiazepines and poor performance in the getting up and walking from one position (Peirce et al., 2018). Each of the independent factors of danger is determined with a certain result (McKechnie, Pryor & Fisher 2016, p 38). In the exceptional case that a component is absent, the patient gets zero score on the fall assessment scale.

Nursing interventions

Pain management

The intense pain related to injury or postoperatively is usually controlled by the regulation of analgesics as approved. The multimodal pain relief organization should include acetaminophen and non-steroidal tranquillizers, unless contraindicated, with opioids, if necessary. Regardless of pharmacologists, commonly used medical mediations to reduce pain integrate patient counseling, physiotherapy, relaxation techniques and exercises (Mann & Carr 2018, p 59). Exercise training can be fundamental to reducing nervousness, increasing pain adaptation, and observing torture. Maintaining patient education and mainstreaming can reduce pain score (Strickland & Baguley 2015, p 6). The nurse professional should inform the patient and the family when the treatment is planned, what is planned. Also, the physician should guide them on the course of pain and regularly allow the patient to control the pain by utilizing relaxation procedures, such as deep breathing, muscle relaxation techniques and visual imaging (Karttunen et al. 2015, p 79). Also, the attendant should help the patient and the family to access all exercises, prescriptions and mediation.

Managing the risk of falling

This patient XX has several progressive "warning" zones, for example old age, osteoarthritis, multiple sclerosis, and vertigo. The use of the risk-reduction risk model " Hendrich II" may be helpful in identifying remarkable risk factors including confusion (4 points), male gender (1 point) and difficulty in getting up from bed (4 point). These risk factors, inspired by Hendrich II's risk model, along with the post-fall overall assessment data, can be useful in conducting medical assessment and, in general, in the patient intervention plan (Hoffmann et al. 2015, p 12).

The goals for administering older adults at risk of falling include targets for the administration of falls, including (1) reducing the likelihood of falling, (2) reducing the risk of harm, (3) the remarkable possible level of reducing gait disturbances i) ensure continuous follow up (McKechnie, Pryor & Fisher 2016, p 38). The clinical approach to fall risk management should involve collaborative efforts with patients and their family members to reduce the risk of falling incidents. In addition, the nurse should talk about the importance of exercise and balance control for patient XX.

Nursing competencies

1.2

Under medical competence 1.2, the nurse must demonstrate the ability to apply the Waitangi / Te Tiriti o Waitangi contract standards as a practicing nurse. In the present case, the nurse prfessional must demonstrate knowledge about the various welfare and financial condition of Maori and non-Maori. The nurse is ought to become the patient’s advocate and prevent any violation of patient’s rights (Temel & Kutlu 2015, p 63). The patient XX has a belief in spirituality and respect other religions and cultures also. He has some knowledge about other cultures and he reads religious and history books to gain more knowledge and calm his mind.

1.5

The nurses ought to practice in a way that the patient feels socially protected. The nurse professionals should be purposeful and effective to connect with the larger family in organizing care. The nurse should be aware about the social responsibilities, cultural practices, and standards, and if the unsure should look for direction from collaborators or different sources. For example, in the present case, medical staff should help patient XX with osteoarthritis to include his family and go to meetings with him when the patient's family is unable to do so (Jones et al. 2015).

The nurse should pay attention to the contrasts between individuals and seek to take care that the client believes he is aware and culturally competent (Baixinho et al., 2016). The nurse must establish a therapeutic relationship of trust with the patient regardless of the religious and cultural differences.

Conclusion

Marjorie Gordon proposed functional opportunities for well-being as a guide to building a comprehensive medical care database with appropriate customer assessment data. Eleven factors are used for categorizing an organized and institutionalized way to cope with the accumulation of information and enable medical staff to decide on the accompanying parts of well-being and human capacity to design the necessary nursing care for their clients. Moreover, a focused assessment is aimed to identify the cause of chief complaints of the patient and thus helps in planning the nursing intervention and plan of care for the patient. The focused assessments in the current scenario include detailed assessment of the patient’s pain scale as well as fall risk assessment. An elderly patient with a history of osteoarthritis and difficulty in mobility is at increased risk of falls. Thus, fall risk assessment is an important aspect of nursing care. Nursing competencies should be kept in mind for safe and ethical nursing practice