Nursing Care Plan

Student: Donna Maas Date: 10/12/12 Client Initials: J.D. Age: 71 Instructor: Professor Horst

Assessment
Data Collection

Diagnosis
Name the Problem Goals/Outcomes (need dates)

Planning and Implementation

Interventions (need dates) Rationales

Evaluation
Goal Met, Partially Met, Not Met

Subjective Data: Age: 71 DOB: 12/20/40 Sex: Female Race: Caucasian Single Non-smoker Non-drinker Allergic to many medications: including coumadin, fentanyl, morphine, hydrocodone, sulfa drugs X-ray- abdomen AP KUB Impressions Include: 1. Smooth calcifications to right of LS related to

Priority #1: Activity intolerance related to muscle rigidity as evidenced by Parkinsons Disease. Rationale: Patient is weak and fatigued and moves rigidly.

Goal #1: Patient 1.1 Assess the patients level of will be able to mobility today. perform required 1.2 Encourage adequate rest activities of daily periods daily during each living with nursing shift, especially assistance by before meals, other ADLs, discharge. exercise session and ambulation. Outcome: Patient 1.3 Encourage patient daily to will demonstrate refrain from performing a measurable nonessential procedures. increase in 1.4 Assist in assigning priority tolerance to to activities daily to activity with no accommodate energy levels. clinical problems 1.5 Establish daily guidelines for three days. 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, resting for at least 1 hour after meals before 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 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 first may better meet the patients needs (Gulanick & Myers, 2011). 1.5 Consistent activity maintains strength, ROM,

#1: Goal is partially met but ongoing. It will be reassessed through the patients 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: Parkinsons disease (chronic), UTI (site Priority #2: Nutritional imbalance: less than body requirements related to sharp abdominal pain rated at 10 and decreased appetite as evidenced by patients 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.

activity, and organizing a work-rest-work schedule.

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 status each day. 2.2 Monitor weight each day. 2.3 Monitor laboratory values daily that indicate nutritional well-being or deterioration, such Outcome: Patient as serum albumin, red and white will not leave blood counts. any food on her 2.4 Suggest high-calorie, lowfood tray that has volume supplements between not been eaten meals daily at the beginning of more than once each nursing shift. per day. 2.5 Each day prior to presenting the patient with her food tray, suggest ways to assist the patient with meals: ensure a pleasant environment, facilitate proper position, and provide good oral hygiene. 2.6 Review and reinforce with

2.1 Bradykinesia, tremors, and rigidity may interfere with feeding, self-care, chewing and swallowing (Gulanick & Myers, 2011). 2.2 Weight loss is usually the result of decreased intake (Gulanick & Myers, 2011). 2.3 Serum albumin is a test that indicates the degree of protein depletion; anemia and leukopenia occur in malnutrition, leading to weakness and indicating anemia and decreased resistance to infection (Gulanick & Myers, 2011). 2.4 Additional caloric intake may be required for optimal nutrition (Gulanick & Myers,

#2: Goal partially met. Patient verbalizes that she is eating a little bit more. Goal is ongoing because it will be reassessed throughout the patients hospital stay.

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 30 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 Parkinsons Disease Cholecalciferol (Vit. D), 2000 units (2 pills daily, given at same time) prevention of falls Objective Data: Weight: 151 lbs. Height: 54 BP: 224/98 supine Temp: 96.4 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.