Mr Slade is a new resident in the nursing home. The Clinical Nurse, Robyn, was assessing him as part of his initial Care Plan development.

Mr Slade is a new resident in the nursing home. The Clinical Nurse, Robyn, was assessing him as part of his initial Care Plan development. While walking with him to the interview room, she noticed he was limping and his trouser leg was slightly stained. She asked him about his limp and its cause. He dismissed her question with ‘Oh, it’s only a scratch from where I caught my leg on the edge of a cupboard’. Robyn persisted with her enquiries and persuaded Mr Slade to lift his trouser leg. Here the ‘scratch’ had turned into a weeping ulcer. Appropriate wound management and referral to the doctor for medication were immediately included in the Care Plan. Discuss this case study in terms of how data may be collected for a client’s Care Plan.

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