1101889 Emma Lumerto

Nursing Care Plan

25.5.2012 1(2)

Case study: 75 yr old man cared for full time by his wife (a former nurse.) Admitted to Jorvi with a urine
infection and other complications from diabetes then sent to Puolarmets for continued care. Wife wants
him to be cared for in a nursing home as she cannot help him alone due to his size (resulting in him falling
several times).
Physiological mode:
Basic:
Oxygenation
Nutrition
Elimination
Activity and
rest
Protection

Complex:
Out of breath when moving. Sleep
apnoea.
High caloric intake. Drinks many
sugary drinks. Eats well and without
aid.
Indwelling catheter. Normal fecal
elimination into diaper.
With the aid of two helpers can walk
a short distance with a stroller. Sits
in wheelchair. Very little physical
activity.
Erysipelas skin infection. Urine
infection. Pressure sores.
Self-concept mode:

Role function mode:

Interdependence
mode:

Senses

Cataracts. Diminished feeling in legs. General

pain and stomach pain. Poor balance.

Fluids and
electrolytes

Good fluid intake.

Neurological
functions

Memory loss. MMSE: 15/30

Endocrine

Diabetes type II

Poor self-confidence due to size and inability to look after

himself without his wifes help? Possible loss of his
identity as memory loss persists? Spiritual questioning as
health continues to decline?
75 year old retired man married to a nurse and father to 3 children. Social integrity might
be disrupted due to: decline in memory, adapting to the role of a patient, changing
environments (home-Jorvi-Puolarmets) and the prospect that he might not live at home
again.
Wife cares for him full time. Regular visits from his children. Had home care visit once a
month to administer Pendysin injections.

Assessment of behaviour
Client is morbidly obese: stomach (c. 158 cm) and is disproportionally big even for his size. Stomach
appears to be getting bigger daily. Arms and legs swollen and skin of his legs is dark, rest of his skin
appears yellowish. Pressure sores on his right side. Residual urine and urine infection. Can walk with the
stroller, sit in a wheel chair or side of the bed with two people helping, but gets out of breath. Can turn
himself in bed. Elimination works well with indwelling catheter and diaper. Rests throughout the day;
would rather stay in bed. Speaking clear, but confused. In overview, the client cannot adapt quick enough
or has not adapted fully to match the change in stimuli.
Assessment of influencing factors
High caloric intake and lack of sufficient exercise due to his size and lack of muscle strength. Shortness of
breath due to poor fitness. Bad balance and orthostatic hypertension. The hospital bed is small and its
harder to turn himself without help. Confusion/ memory loss contribute to him lying too long on one side
causing pressure sores.
Nursing diagnosis
Morbidly obese due to high caloric intake, lack of activity and size. High calorie diet and life are
contributing factors to type II diabetes which has probably played a role in cataract, edema and
diminished feeling in legs. Erysipelas is also common in those with diabetes.
Fatigue likely caused by his weight, poor fitness, urine infection and its also reported as a side effect of
erysipelas. The urine infection could be caused by insufficient hygiene especially as he has an indwelling
catheter and diabetes. Yellowish skin colour could be related to liver problems. Little activity and plenty
of resting throughout the day could be because of sleep apnoea (due to his weight) and not enough quality

1101889 Emma Lumerto

Nursing Care Plan

25.5.2012 1(2)

sleep. Perhaps also confusion, dizziness (from orthostatic hypertension) and disorientation dont help
motivate him to be active. His low motivation could be linked to the self-concept mode. Cause of stomach
pain and swelling is unknown.
Goals
Short term: Recognise relationship between healthy diet, exercise and weight. Nutrition/food diary.
Lower caloric intake, especially by cutting down on sugary drinks. Eat daily in the corridor/ side of the
bed. With help to sit in the wheel chair daily, do wheel chair exercises. To do activities in the day go to
viriketoiminta once a week.
Long term: Reach and maintain a healthy weight. Be able to walk surely with the stroller. Regular exercise
and manage diabetes.
Interventions
Involve the family in encouraging the patient to keep his goals (not to bring him many snacks). Talk to the
wife frankly with adequate amounts of information. Show the patient a food pyramid and educate him
about a healthy balanced diet with the aid of a nutritionist. Educate the patient on good diabetes
management.
Discuss the home care service with the wife. If possible, arrange for a home visit trial with home care
before nursing homes. Include physiotherapists to aid with exercise and moving the client from bed to
wheel chair daily. Let the patient sit for a while before standing to reduce dizziness.
Talk to the doctor about stomach pain and swelling. Monitor with measuring circumference daily. Take
blood pressure, fluid list, monitor temperature (due to the infection) and measure weight regularly for
progress. Manage pain with therapeutic methods before medication. Give bed baths if the patient cannot
walk to the bathroom. Wash around the entrance to the catheter with good aseptic techniques. Manage
bed sores by good positioning and skin care; encourage him to not lie on one side for too long. Aid in
turning. Monitor memory with MMSE tests.
Evaluation
Client did not reach long term goals, perhaps not being able to adapt sufficiently to the rate of decline in
health. Family also continued to bring sugary drinks, but otherwise calorie intake was regulated by the
meals in the ward.
Physiotherapy rehabilitation started well with him sitting at the side of his bed to eat and to sit in the
wheel chair but because his stomach swelled so much he couldnt sit comfortably or lie on his back.
Physical activity declined even further.
The doctors found an enlarged liver and cirrhosis in its late stages. The patient was transferred back to
Jorvi and came back as a bed ridden patient, semi-conscious, very confused. Oxygenation saturation
declined so that he needed oxygen via nasal cannulas, urination was bloody and decreasing in output daily.
Patient appeared in pain and no longer took food. Fluid and electrolytes intake was good. Patients eyes
remained open.
Recommended Good palliative care. Honest communication especially with the former nurse wife.
Encourage family to visit often. Pain management and continued observations due to inability of patient
to communicate. Talk to patient as if conscious. Monitor oxygen saturation levels. Good positioning care
with pillows, minimize creases in clothes and sheets and good skin care- taking care of the older pressure
sores. Ask doctor about getting him a decubitus mattress to further prevent sores. Pureed food first; last
resort nutrient drinks. Move the patient to a more private room. Prepare the family for the clients death
and give them privacy and care.