Care Plan 2 3e1c22

P a g e | 95

Nursing Care Plan Meggan Nanton NorQuest College NPRT 2102 Acute Care Clinical Practicum Instructor: Rhonda Meredith June 03, 2014

P a g e | 96

Nursing Assessment Tool: A Systems Approach SYSTEM

ASSESSMENT

FINDINGS

Respiratory System

 Respiratory rate and rhythm



Cardiovascular System

 History



Nervous System

 Level of consciousness –Glasgow

 Blood pressure & Pulse

Client has a history of M.I.  Recent blood pressure and Pulse were within normal limits according to the chart. 

Client oriented to person, place and time.



Client has not taken anything for pain in the previous 24hours.



Client is susceptible to pain however due to perineal cellulitis, a wound packed dressing on his back and a recent wound vacuum procedure done yesterday to his scrotum.

 Food intake



 History



 Height



 Weight



Client is on a diabetic/Heart Healthy Diet and yesterday was NPO. Client has high cholesterol Client is 175 cm 91kg Client’s BMI is 29.71(preobese) Will need to assess client for regular bowel sounds and for pain. Client’s C.B.C.’s, Bun and Creatine lab val;ues are to be monitored.

Coma Scale  Evidence of pain – acute or chronic

 Description of pain experience –

location, source, onset, duration

Gastrointestinal System

Recent respiratory rate was within normal limits according to the chart.

 Body Mass Index(BMI)

 Bowel sounds

 

 Pain   Fluid intake & output 24 hours



P a g e | 97

SYSTEM Urinary System

ASSESSMENT  Urine –amount, colour, transparency,

odour

Musculoskeletal System

Integumentary System

Client has a Foley  Client’s urine yesterday was clear and Foley was draining adequately according to the chart 

 Posture, gait, coordination



Client had a fall on May 17th, 2014, due to mismanaged blood sugars.

 Evidence of injury/trauma



Client fell on scrotum which led to scrotal damage.

 Condition of skin, scalp, nails, mucous



Skin around scrotum and back will need to be assessed and wound care done as required.



The client’s temperature yesterday was within normal limits according to the chart.

membranes

 Body temperature

Endocrine System

FINDINGS

 Structural change in skeleton, adipose



Monitor scrotum, and back for changes in the wound tissue.

 Endocrine sytem



Check blood sugars four times a day.

 Pathological History



Client is classified as aNonInsulin Dependent diabetic.



Client’s C.B.C.’s, Bun and Creatine lab val;ues are to be monitored.

tissue, integument  Functional change in:

 Lab test findings Senses

 Degree of function and effects of

altered sensation in each of the senses: vision, hearing, touch, smell, taste



Client wears glasses and upper dentures.

P a g e | 98

SYSTEM Environmental Factors that Affect Function of Systems

ASSESSMENT  systems

 Lifestyle factors

 Medical diagnoses

 Medications

 Determinants of health

FINDINGS The patient lives with brother and son, who have been working with the social worker on decisions regarding his care.  Clients’s last job ended in February and he currently does not have health benefits. 



He has Non-Insulin Dependent Diabetes, has previously had a heart attack and has high cholesterol.



Patient takes Acetylsalicylic Acid, Atorvastatin, Calcium Carbonate, Centrum Forte, Heparin Sodium, ImipenemCilastatin Sodium MB-Plus, Metformin, Metoprolol, Nystatin, Ramipril, Toronto, Human Insulin and Vitamin D. His P.R.N medications include Dilaudid, Gravol, Tylenol, Tylenol # 3 and Zofran.



The Client is affected by the “Income and Social Status,”determinant of health as outlined in Potter and Perry (2010, p.6,7). He fell because he was not managing his diabetes accordingly because he could not afford the medication according to the chart.

P a g e | 99

Nursing Care Plan Nursing Diagnosis

Planning

Interventions

Evaluation

Actual Problem: Impaired Tissue Integrity of the Scrotum and the Back related to the patient’s poor diabetic management as evidenced by his falls.

Goal: To prevent further skin breakdown on the patient’s Scrotum and Back.

1 –The student practical nurse will consult with the head nurse and the dietician to assess what methods would work best to prevent these wounds from becoming exacerbated.

S: Patient will participate in a wound survey.

2-Student will cleanse and provide tissue care as needed.

1. Achievement of Expected Outcomes: The goal was met as the patient’s wounds on both his scrotum and back did now worsen as evidenced by the unchanging measurements.

M: Patient will then list 3-4 things,

3-Discourage the patient from scratching or touching his wounds.

A: that he himself can do to prevent the deterioration of the wound.

Rationale for Interventions

R: He can do so in collaboration with the ideas of the Dr., nurses, Pharmacist and Dietician.

1. Taking an interdisciplinary approach with patients gives the client the best outcome when caring for a wound (Potter & Perry, 262).

T: This goal will commence June 3rd to June 6th, 2014.

2. First of all cleansing is important to remove harmful microorganisms and debris and secondly tissue care is vital

2. Patient Responses and Findings: The patient also stated that by doing a wound questionnaire it enabled him to proactively care for his wounds and helped to prevent the further progression of the wounds. 3. Further Nursing Actions: The Outcome was met as indicated by both wounds lengths and widths (they remained the same)|.

P a g e | 100

because “the dressing replaces the protective function of the injured tissue during the healing process”(Gulanick & Myers, 2014 p.196). 3.The above actions according to Gulanick and Myers can worsen the wound and slow down the healing process(2014, p.196).

P a g e | 101

Potential Problem: Risk for Falls related to the patient’s unstable blood sugars as evidenced by his fall on May 17th, 2014.

Goal: To prevent client from 1. The student nurse will assess the experiencing more falls. client for signs of confusion. S: The patient will wear well fitted shoes when walking, wear pajamas and robes that do not drape on the ground and will avoid wet and uneven surfaces. MA: The client will display these behaviours everyday R: during the practical student nurses shift from 7:00-2:00. T: This goal will be maintained from June 3rdJune 20th, 2014.

2. The student will answer the patient’s call bell as soon as possible. 3. Encourage the patient to have their bed in the lowest position possible and to ring for help if they need assistance getting out of bed.

Rationale 1. A confused state of mind is often linked to dizziness, loss of one’s sense of position and ultimately loss of balance (Day, Paul, Williams, Smeltzer, and Bare, 2010, p. 234). 2. Patients who have to wait an extended period of time may do unsafe activities on their own if they have to wait too long (Gulanick & Myers, 2014, p.65). 3. According to Potter and Perry, falls in older adults are often caused by getting out of bed too quickly and without assistance (2010, p. 396).

1. Achievement of Expected Outcomes: The Goal was achieved primarily because the patient strived to wear the right attire while in the hospital and was more careful noting what surface he was walking on. 2. Patient Responses and Findings: This goal was also successful because the patient was motivated to learn. 3. Further Nursing Actions: Are not needed because the patient goal was met and patient vows to be more careful and take all of his medications in the future (social assistance for this pending).

P a g e | 102

Educational: Knowledge deficit: Ineffective Health maintenance as evidenced by patient’s smoking status.

S-Patient will be able to discuss the side effects of smoking with the student nurse. M-The Patient will describe two ways in which smoking affects their diabetic condition and how their heart works. A-Patient is alert and aware and cognitively capable of verbalizing the side effects of smoking. R-This goal is attainable as the patient can be given educational aides o research this topic. T-This discussion will take place between June 3rd and June 6th, 2014.

1 – I: The student practical nurse will discuss the benefits of quitting smoking with the client. 2. I: Talk about smoking cessation aides with the patient such as the patch, gum and prescriptions like Wellbutrin. 3.-I: Discuss with the patient coping methods to not smoke too alleviate stress or anxiety.

Rationale 1. Quitting smoking cuts the risk of Coronary Heart disease by 50% and following 2 weeks-3 months of quitting smoking, one’s circulation is improved(Gulanick and Myers, p. 227) 2. Smoking cessation is twice as affective when nicotine replacement methods are used as opposed to a placebo (Gullanick and Meyers, p.227). 3. Smoking according to Gullanick and Meyers is often used to combat stress,

1. Achievement of Expected Outcomes: The goal was achieved as the patient willingly participated in all discussions. 2. Patient Responses and findings: The interventions were especially helpful to the client as teh client did not realize how much more successful people were, when they incorporated nicotine replacement therapy into quitting smoking. 3. Further Nursing Actions: The client now understands why it is important to quit and consequently the next nursing action would be encouraging the client to quit.

P a g e | 103

however alternative methods exist that can be prescribed such as deep breathing, exercising and ing local groups (2014, p.228).

P a g e | 104

Summary A nursing diagnosis according to Durand & Prince is “the nurse’s perspective on the appropriate focus for the client (Potter & Perry, 2010, p. 64)”, and is the first step in the nursing process. This integral part of nursing care helps the nurse determine what problems are present and furthermore what nursing interventions will work to solve these problems (providing decisions are evidenced based). In this case, evidence based interventions and outcomes helped me to decide that the patient needed help with his wound care (an actual problem), and guidance to prevent him from falling again (a potential nursing diagnosis). The nursing process furthermore prompted me to form an educational goal, and through this structured way of thinking I knew I needed to teach my patient more concerning the ill effects of smoking and to evaluate whether my teachings were effective or not .

P a g e | 105

References:

Day, A.R., Paul, P., Williams, B. Smeltzer, S.C., Bare, B. (2010). Brunner & Suddarth's textbook of Canadian medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins. Gulanick, M., Myers, J.L., (2014). Nursing Care Plans: Diagnoses, Interventions and Outcomes(8th ed.).Philadelphia, PA: Elselvier Potter, P.A., & Perry, A.G. (2010). Canadian fundamentals of nursing (4th ed.). Ross-Kerr, J.C., & Wood, M.J. (Eds., Cdn. ed.). Toronto, ON: Elsevier.