Nursing Care Plan Student: Donna Maas
Date: 10/12/12
Assessment
Diagnosis
Data Collection
Name the Problem
Subjective Data: Age: 71 DOB: 12/20/40 Sex: Female Race: Caucasian Single Non-smoker Non-smoker Non-drinker Non-drinker Allergic to many medications: including coumadin, fentanyl, morphine, hydrocodone, sulfa drugs X-ray- abdomen AP KUB Impressions Include: 1. Smooth calcifications calcifications to right of LS related to
Priority #1: Activity intolerance related to muscle rigidity as evidenced by Parkinson’s Disease. Rationale: Patient is weak and fatigued and moves rigidly.
Client Initials: J.D. Age: 71
Instructor: Professor Horst
Planning and Implementation Goals/Outcomes (need dates)
Goal #1: Patient will be able to perform required required activities of daily living with assistance by discharge. Outcome: Patient will demonstrate demonstrate a measurable increase in tolerance to activity with no clinical problems for three days.
Evaluation
Interventions (need dates)
Rationales
1.1 Assess the patient’s level of mobility today. 1.2 Encourage adequate rest periods daily daily during each each nursing shift, especially before meals, meals, other ADLs, exercise session and ambulation. 1.3 Encourage patient daily to refrain from performing nonessential procedures. 1.4 Assist in assigning priority to activities daily to accommodate energy levels. 1.5 Establish daily guidelines and goals of activity with the patient and caregiver. 1.6 Teach energy-conservation techniques daily such as sitting to do tasks, changing positions often, often, resting for at at least 1 hour after meals before starting starting a new
1.1 This information will serve as a basis for formulating realistic shortand long-term goals (Gulanick & Myers, 2011). 1.2 Rest between activities provides time time for energy conservation and recovery (Gulanick & Myers, 2011). 1.3 Patients with limited activity tolerance need to prioritize tasks (Gulanick & Myers, 2011). 1.4 With reduced functional capacity, pacing of priority tasks tasks first may better meet meet the patient’s needs (Gulanick & Myers, 2011). 1.5 Consistent activity maintains strength, ROM,
Goal Met, Partially Met, Not Met
#1: Goal is partially met but ongoing. ongoing. It will be reassessed through the patient’s hospital stay. Teaching is being provided to patient daily regarding adequate rest, conserving energy, and prioritizing tasks.
ovarian phleboliths 2. Prominent degenerative changes in spine with scoliosis 3. Changes in bilateral hip. Surgical failure of screws. Lab Work Values Indicate: ↑Co2 -3.3 (21-32 mmol/L) ↓Total protein 6.3 (6.4-8.2gldL) ↓Anion gap 7. (10-20 mmol/L) ↑Glucose 1.02 (65-99 mg/dL) ↑Bun/Creatinine Ratio 32 (7-25) ↑ Neutrophil 70% (33-69%) Present health history: Parkinson’s disease (chronic), UTI (site
activity, and organizing a work-rest-work schedule.
Priority #2: Nutritional imbalance: less than body requirements related to sharp abdominal pain rated at 10 and decreased appetite as evidenced by patient’s verbal statement of no solid intake x2 weeks prior to admission Rationale: Patient reports drinking 2-3 Ensures daily for 1-2 weeks with little else before hospitalization and total protein in lab
Goal #2: Patient will eat all of the food on her food tray for three days.
and endurance gain (Gulanick & Myers, 2011). 1.6 Energy-conversation techniques reduce oxygen consumption, allowing for more prolonged activity (Gulanick & Myers, 2011).
2.1 Assess overall nutritional 2.1 Bradykinesia, tremors, and #2: Goal status each day. rigidity may interfere with partially met. 2.2 Monitor weight each day. feeding, self-care, chewing Patient 2.3 Monitor laboratory values and swallowing (Gulanick & verbalizes that daily that indicate nutritional Myers, 2011). she is “eating well-being or deterioration, such 2.2 Weight loss is usually the a little bit Outcome: Patient as serum albumin, red and white result of decreased intake more.” Goal will not leave blood counts. (Gulanick & Myers, 2011). is ongoing any food on her 2.4 Suggest high-calorie, low2.3 Serum albumin is a test because it will food tray that has volume supplements between that indicates the degree of be reassessed not been eaten meals daily at the beginning of protein depletion; anemia and throughout more than once each nursing shift. leukopenia occur in the patient’s per day. 2.5 Each day prior to presenting malnutrition, leading to hospital stay. the patient with her food tray, weakness and indicating suggest ways to assist the anemia and decreased patient with meals: ensure a resistance to infection pleasant environment, facilitate (Gulanick & Myers, 2011). proper position, and provide 2.4 Additional caloric intake good oral hygiene. may be required for optimal 2.6 Review and reinforce with nutrition (Gulanick & Myers,
not specified), depressive disorder (chronic) Kidney disease (chronic) Depression Anxiety Difficulty walking Past health history: Cardiac failure (congestive) Essential (primary) Hypertension Hyperlipidemia Esophogial reflux anemia Surgical History: Appendectomy Hysterectomy Gallbladder removal Back surgery Eye surgery Joint replacement Fracture surgery Service to gastroenterology Medications include: Augmentin 500-125
work is down to 6.3 (normal is 6.4-8.2 gldL).
the patient and caregiver daily, the basic four food groups and the importance of maintaining adequate caloric intake.
2011). 2.5 Elevating the head of the bed 30º aids in swallowing and reduces risk for aspiration (Gulanick & Myers, 2011). 2.6 Patients and/or caregiver may not understand what is involved in a balanced diet. They are better able to ask questions and seek assistance when they know basic information (Gulanick & Myers, 2011).
mg., 2x daily for infection CarbidopaLevodopa 25-100 mg, 6x a day for Parkinson’s Disease Cholecalciferol (Vit. D), 2000 units (2 pills daily, given at same time) – prevention of falls Objective Data: Weight: 151 lbs. Height: 5’4” BP: 224/98 supine Temp: 96.4º F. - oral Pulse: 67 radial Respirations: 20 SpO2: 93% Rigidity Tremors Limited movement Weakness Fatigue Gulanick, M. & Myers, J. (2011). Nursing care plans, diagnoses, interventions, and outcomes. (7th ed, pp. 8-11, 142-144, 519-520). PA: Mosby.
