Sample - Nursing Care Plan for a Surgical Setting Patient

Nursing Assignment Help and Essay Sample - Nursing Care Plan for a Surgical Setting Patient

PART 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

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PART 2: CARE PLANNING                                                                                                                                         

Nursing Care Plan

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PART 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.

PART 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.

PART 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.  

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