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Nursing Care Plan Assignment Sample - Nursing Care Plan for a Surgical Setting Patient
Nursing Care Plan Sample
Nursing Care Plan for a Surgical Setting Patient
Task 1: Patient assessment
Nutrition assessment
Nutrition assessment is critical for a patient with a medical history of Hypertension on admission because it identifies the specific food and fluid requirement during her stay at the hospital. It is important to identify the level of care based on how critical the disease is as well as the nutritional balance when administering food. Nutrition with low salt and high potassium will have great influence on the patient blood pressure (Nkosi et al., 2010). Failure to conduct this assessment could result in healthcare providers failing in identifying what special care dietary the patient requires such as IV fluids for nutritional balance or special medication the patient has been using.
Functioning and Mobility assessment
Functioning and Mobility assessment are important in establishing the overall strength of the patient. This assessment relates to the patient’s previous report as well as that by her husband on an increased number of falls. Specific aspects related to this assessment include daily living activities, instrumental elements of family living, exercise status, balance and gait (Zwar et al., 2017). Assessment of these aspects determines the patient’s stability, strength of her body, and the likelihood of falls. Failure to properly conduct these tests may result in more falls at the hospital resulting in further medical complications such as fractures. Improper mobility assessment may also impede any help to the daily living that could be crucial to the patient’s welfare.
Cognition assessment
Cognition assessment is essential in identifying cognitive and mood disorders prompting for more medical and therapeutic intervention. The medical history of the patient includes hypertension, hypercholesteremia, as well as poor memory. Also included in the description is that she just feels weak and sometimes quite anxious and breathless and her age is a factor to be considered. Martin et al., 2009 stressed that about ‘30% of older people attending hospital services’ are affected by cognitive impairment. Failure to effectively conduct this assessment may present a challenge in identifying the cognitive requirements of the patient which may deter proper care as she may forget her medication or daily living activities
Task 2: Care planning
Nursing Care Plan: Joyce
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Nursing problem: High falls risks |
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Underlying cause or reason: The patient is aged and weak. She has also expressed several falls at home |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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Reducing and avoiding the number of falls
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Hourly rounding in the patient unit at night to monitor their state of sleep as well as identifying whether they require any assistance. During the day, or when the patient is moving around, it is important to provide support to avoid falling since she is weak. There should also be someone observing the patient and monitoring their activities to detect any signs or falling possibilities and therein take corrective action
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Upon admission of a patient, one of the main challenges that affect their stay at the hospital is an increase in the number of falls. These emanate from the fact that they are confined to their beds and may have their personal requirements and needs such as going to the washrooms (Lewis et al., 2016). Since these patients are weak, they will most likely fall. Another aspect justifying this planning care is the patient’s need to move around, and since they are weak, their likelihood to fall is high and should be averted. It is therefore critical to monitor the patient and regulate their activities which avoid or reduce falls |
Patient expresses satisfaction in the care they receive as well as having their personal needs, reduced number of falls and prevention of injuries. |
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Nursing problem: Decreased activity tolerance |
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Underlying cause or reason: The patient is aged, and according to the husband, he assists her in various activities although of late she has been slowing down. She is becoming fatigued and tired faster thus her ability to do various activities is limited |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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Enhance the patient’s activity tolerance |
Enhancing the patient’s tolerance requires several approaches including improving their strength to do various activities, assisting the patient if she has any requirements and avoiding straining her too much. For the patient’ weakness, it involves improving her eating habits while addressing her requirements involve assisting her conduct various activities and stopping at a point where she shows strain |
According to the initial assessment, the patient has already portrayed weakness signs, and as suggested by her husband, she is slowing down and gets fatigued fast. While increasing her dietary intake enhances her strength, refraining her from struggling through assisting her in personal needs is important in reducing the rate of fatigue (Feo & Kitson, 2016) |
The patient shows signs of strength and can perform an array of activities comfortable without straining |
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Nursing problem: Nutritional imbalance |
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Underlying cause or reason: Based on the initial assessment, Joe asserts that although at times they cook healthy meals, there are increasingly relying on snack foods and heating frozen meals for convenience. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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Improving nutritional balance in her meals |
Providing freshly cooked meals that contain various nutrients from vitamins to proteins. It is also important to involve a dietician and develop a meal plan that reflects on a regular balanced diet. Some of the aspects to consider include taking lots of fruits and drinking plenty of water. |
The patient already portrays general body weakness which can be deduced from poor dietary habits. Her nutritional balance can be related to the increased intake of frozen meals and snacks for convenience purposes. Notably, snacks which form part of poor dietary habits render the patient’s body nutritionally imbalanced and should be discouraged (Browne et al., 2014). The intake of fresh foods with a dietician developed meal plan ensures all nutrients are present (Nkosi & Wright, 2010). |
The patient should show signs of increased strength. |
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Nursing problem: Cognitive welfare |
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Underlying cause or reason: According to the patient’s medical history of hypertension and hypercholesteremia, she is a poor historian. According to her, the memory is not as good as it was |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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Enhancing the patient’s cognitive well-being
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Increased exercises to improve her health and therein enhancing her sleep at night. Dietary balance and in particular intake of foods rich in vitamin B. Her husband should also be present most of the time to enhance her mental stability while averting possible situations such as mood disorder and depression. Her socialization ability should be enhanced through approaches such as promoting interaction with other patients and healthcare providers. To ensure that she is not anxious over the change in environment, she should have all her specific needs availed such as a phone to communicate with her husband. |
As a patient ages, her memory is also affected which can also be caused by the hypertension condition. Altering her environment may present other mental challenges such as depression and mood disorders. To avert these and enhance her cognitive well-being, it is critical to ensure her environment is according to most of her specifications (Carthon et al., 2015). On the other hand, it is important to have a patient’s closest person near them most of the time particularly if their mental wellbeing is challenged |
Patient should be satisfied with the care they receive, and signs of anxiety, depression and mood disorder should be minimal |
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Nursing problem: Reduced personal hygiene |
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Underlying cause or reason: According to the initial assessment, it is apparent that she was being assisted by her husband in conducting her personal activities. This includes personal hygiene. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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Ensuring personal hygiene
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Ensuring high hygiene of the student and their environment through regular cleaning and assisting the patient improve her personal hygiene. |
The patient was being assisted by her husband to take care of herself, an aspect that has changed upon being hospitalized. It is therefore critical for the nursing care to develop strategies through which the patient’s cleanliness can be enhanced (Zwar et al., 2017). This includes promoting their personal hygiene and that of their environment. Poor patient hygiene is related to microbial infections which may prolong the patient’s stay at the hospital. |
Patient should be clean and there are no hygiene affiliated conditions such as bacterial infections |
Task 3: Medication management
Daily Atorvastatin taken at 20 mg dosage is important to Joyce for preventing heart attack and lowering her cholesterol. According to her medical history, she has Hypertension, a heart condition and hypercholesteremia related to cholesterol. Joyce’s age is also advanced thus regular exercises and healthy diet to control her weight may not be fully effective. This medication is used together with diet, exercises and weight loss (Ray et al., 2014). Nursing responsibilities associated with this medication include taking it at the right time and administering the right dosage. Key side effects to look out for include diarrhea, heartburn, confusion, memory loss, heartburn. Severe effects include upper abdominal pain, dark urine, and appetite loss.
Ramipril 10mg daily strength is important in treating high blood pressure and mitigating the risk of heart attack. According to her medical history, she has had hypertension which is treated with this medication among others. In addition, her current blood pressure is at 150/95 which is at a higher level hence this medication may be used to reduce it. Specific nursing responsibilities are ensuring the medication is taken on a daily basis, and since Joyce is aged, the nurse should check for side effects which may result from piling up of the medicine in the body (American Diabetes Association, 2016). These include dizziness, weakness cough, vomiting, and diarrhea. Serious side effects include breathing challenges and swelling of the legs and hands.
Aspirin 100mg strength daily is for pain loss and preventing heart attacks. Joyce has had several falls resulting in pain from several parts of the body. Her blood pressure is high and has a medical history of hypertension thus a risk for heart attack. Aspirin in this regard is for mitigating this risk. Specific nursing responsibilities include ensuring the drug is taken in good form and at recommended levels (Lewis et al., 2016). It is also important to look out for several side effects such as confusion, allergic reactions, breathing challenges, swallowing pain and general body weakness.
Task 4: Patient teaching
Hypercholesteremia
Lifestyle modification education is critical for Joyce as hypercholesteremia can be averted effectively through regular exercise, dieting, and the addition of plant sterols in foods. During her stay at the hospital, beside the pharmaceutical approach in addressing hypercholesteremia, non-medication management will also be critical as this will enhance her mobility and improve her health status (Sniderman, Tsimikas, & Fazio, 2014). The importance of teaching her about lifestyle modification is centered on working with her to implement the modification management strategies. A holistic management of a condition which involves patients and health care providers working together is important to achieving desired patient outcome. Identifying whether Joyce has understood the teachings is reflected in her commitment towards the specific elements in the education program. The intervention strategies for lifestyle modification will involve loss of weight, aerobic exercises and decrease cholesterol using plant sterols. Some specific elements in the education will include reducing intake of saturated fats and cholesterol while increasing intake of dietary fiber, unsaturated fats, and complex carbohydrates (Sniderman, Tsimikas, & Fazio, 2014). She will also be trained on measuring her daily nutrient intake and fats levels. Specific figures to observe in her daily meals include total fat of 25%-35%. For exercises, aerobics are important in weight loss and enhancing blood flow. An important aspect that should be emphasized in the teaching is that balanced diet and exercises should be implemented concurrently.
Task 5: Clinical judgment and handover
A. Clinical judgement
According to the results of further assessment which include a respiratory rate of 28-32 breaths per minute, oxygen saturation of 84% on room air, blood pressure of 90/80 mmHg among others reflect on a possible myocardial infarction (MI). This assertion is based on the symptoms of the condition including shortness of breath, low pulse rate, and low blood pressure (Puskarich, Nandi & Jones, 2015). The condition has probably been caused by possible blockage of the arteries or build-up of plaque and narrowing of the arteries. Other aspects suggesting on the MI condition include bad cholesterol as reflected in patient’s initial assessment where she has hypercholesteremia (Ray et al., 2014). Initial nursing intervention on the condition is based on the condition the patient is in the morning including being anxious where she mentions that she wants to call Joe. It is therefore critical to calm her down through calling Joe for instance and assuring her that he is okay and will be with them shortly. Another intervention will be the administration of antianginals (nitroglycerin) which will increase coronary blood flow. Notably, nitrates are important in mitigating the effects of MI, and although the patient notes not being in pain, the urgent medication will be effective based on the fact that peripheral vasodilation decrease preload thus reducing oxygen demand and myocardial workload.
B. Handover.
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Introduction |
From nursing officer in the emergency department To Coronary care unit Patient: Joyce, a 76-year-old female |
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Situation |
I am calling for the admission of this patient to your unit for further and comprehensive monitoring and management. This morning as I was removing the patient’s tray, I realized that she had not taken breakfast, and upon being questioned, she mentioned poor sleep at night and anxiousness as a result of her husband being on his own. She mentioned no pain besides slight indigestion. She is also irritated and forces me to leave. Upon returning after some few minutes, she is agitated extremely and attempts to get off her bed to call her husband. Her skin is pale and slightly bluish gray. She is breathing slowly with shallow and rapid respirations. Her skin is moist and has swollen ankles. Other assessment details include respiration rate of 28-32 breaths per minute, oxygen saturation of 84% on room air, weak and thread radial pulse, faint blood pressure of 90/80 mmHg. |
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Background |
Joyce is a 76-year-old female student who has been admitted as a result of falls at home and Acopia. Initial assessment shows the patient had hematomas to her left eye and bilaterally on her knees. Her medical history shows hypertension and hypercholesteremia. She also has a poor memory. She has been using the following medicines, Atorvastatin (20 mg daily), Ramipril (10 mg daily) and Asprin (100mg daily). |
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Assessment |
Vital signs are faint pulse rate, low blood pressure, and anxiety. Primary suspicion is Myocardial infarction (MI) based on the high cholesterol levels among other symptoms. So far we have calm the patient and have administered antianginals (nitroglycerin) to stabilize her. Aspects recorded include 140 beats per minute, 28-32 breaths per minute and blood pressure of 90/80 mmHg. |
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Recommendation |
I request the coronary care unit to further and deeply monitor this patient and provide a comprehensive report on her condition. |
References
American Diabetes Association. (2016). 8. Cardiovascular disease and risk management. Diabetes Care, 39(Supplement 1), S60-S71.
Browne, S., Macdonald, S., May, C. R., Macleod, U., & Mair, F. S. (2014). Patient, carer and professional perspectives on barriers and facilitators to quality care in advanced heart failure. PLoS One, 9(3), e93288.
Carthon, J. M. B., Lasater, K. B., Sloane, D. M., & Kutney-Lee, A. (2015). The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: A cross-sectional study of US hospitals. BMJ Qual Saf, bmjqs-2014.
Feo, R., & Kitson, A. (2016). Promoting patient-centered fundamental care in acute healthcare systems. International journal of nursing studies, 57, 1-11.
Turner, A., Eccles, F. J., Elvish, R., Simpson, J., & Keady, J. (2017). The experience of caring for patients with dementia within a general hospital setting: a meta-synthesis of the qualitative literature. Aging & mental health, 21(1), 66-76.
Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences.
Puskarich, M. A., Nandi, U., & Jones, A. E. (2015). Persistence Of Tachycardia And Tachypnea Are Associated With Mortality In Normotensive Emergency Department Patients Admitted To The Hospital. Academic Emergency Medicine, 22, S217.
Nkosi, N., & Wright, S. (2010). Knowledge related to nutrition and hypertension management practices of adults in Ga-Rankuwa day clinics.Curationis, 33(2), 33-40. doi:10.4102/curationis.v33i2.1083
Martin, R., & O'Neill, D. (2009). Taxing your memory. The Lancet, 373(9680), 2009-10
Ray, K. K., Kastelein, J. J., Matthijs Boekholdt, S., Nicholls, S. J., Khaw, K. T., Ballantyne, C. M., & Lüscher, T. F. (2014). The ACC/AHA 2013 guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: the good the bad and the uncertain: a comparison with ESC/EAS guidelines for the management of dyslipidaemias 2011. European heart journal, 35(15), 960-968.
Schroedl, C. J., Yount, S. E., Szmuilowicz, E., Hutchison, P. J., Rosenberg, S. R., & Kalhan, R. (2014). A qualitative study of unmet healthcare needs in chronic obstructive pulmonary disease. A potential role for specialist palliative care? Annals of the American Thoracic Society, 11(9), 1433-1438.
Sniderman, A. D., Tsimikas, S., & Fazio, S. (2014). The severe hypercholesterolemia phenotype: clinical diagnosis, management, and emerging therapies. Journal of the American College of Cardiology, 63(19), 1935-1947.
Sav, A., King, M. A., Whitty, J. A., Kendall, E., McMillan, S. S., Kelly, F., & Wheeler, A. J. (2015). The burden of treatment for chronic illness: a concept analysis and review of the literature. Health Expectations, 18(3), 312-324.
Zwar, N., Harris, M., Griffiths, R., Roland, M., Dennis, S., Powell Davies, G., & Hasan, I. (2017). A systematic review of chronic disease management.
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