NURSING CARE PLANBy: Reema H. Matar

Adult 1

Admission Data Base

• Client: A.A.A• Age: 66 years old• Sex: Male• Spoken language: Arabic• Date of Admission: 12/4/2011 … Via: Emergency Department• Source of Data: File, Patient, Family, and Physiotherapist• Condition on arrival: Wheelchair

• Reason for Hospitalization:

Patient suffered of severe left side pain after falling on left leg

• Confirmed Diagnosis:

Femur neck fracture

Dynamic Hip Screw!

History• Past Medical History:

Diabetes Mellitus (since 15 years )

Hypertension (since 15 years)

Old stroke (13 years ago)• Past Surgical History:

Cataract for both eyes – University Hospital

Chest drainage• Family History:Key:

: Male

: Female

: Patient

: Dead

: Household members

: Married

Assesment (Subjective Data)

• Health Maintenance – Perception Pattern

Smoking: …. Yes (3-4 packs/day)

Alcohol: … No

Allergies: …. No

• Activity/Exercise Pattern

Activity 1-Independant

2- needs assistance

3 -dependant

Feeding

Bathing

Dressing

Toileting

Mobility

• Nutrition/Metabolic Pattern

Diet: Regular

Prescribed diet: Low Salt

Dentures: upper and lower

• Elimination Pattern

Used to complain of chronic constipation (going once per two weeks) but no

longer complains due to Dalcolax medicine

(laxative)

• Sleep/Rest Pattern:

Usual number of hours/night (7-8) takes AM and PM naps

After hospitalization the patient complains of not being able to sleep due to pain of left side.

• Cognitive/Conceptual Pattern:

After doing cataract surgery for both eyes, the patient now

sees well in both eyes

• Coping Stress/Self Perception Pattern:

Major Concern: The patient does not like the hospital and is very upset regarding elimination in diaper. He says “I don’t like having to let the nurses change me”.

Major Change: Cannot move due to prescribed immobilization

Coping Mechanisms: Talks to neighbors and family

• Value – Belief Pattern:Muslim

• Role – Relationship Pattern:

Retired, and lives with his 2 sons, wife, and daughter

Physical Examination (Objective Data)

• 1.General Survey:Level of Consciousness: Awake, alert,

conscious

Orientation: Aware of place, time, and persons

Height: 168 cm

Weight: 65 kg

Temperature: 36.5 C

• 2. Nutritional – Metabolic Pattern:

• (A).SKIN:Color: tan - brownSymmetrical: Yes, bilateralTemperature: WarmTurgor: Elastic, mobile, return quicklyTexture: SmoothMoisture: DryLesions: Yes, incision woundEdema: NoPruritus: NoTubes: No

• (B) Oral Cavity:Lips: No lesionsGums: Pink, no masses or lesionsTeeth: Upper and Lower denturesTongue: Protrude in midline, no lesionsMucous membrane: mucosa and gingivae

pink, no masses, no lesions

• (C) Neck:Symmetrical: YesThyroid: Not palpable, no bruitsCarotid Pulse: Smooth rapid upstroke,

slower down stroke, equal bilateral, +2Jugular Venous Pressure: Present when

supine, disappear at 45 degree position.

Lymph Node Enlargement: No

• (D) Abdomen:Symmetrical: YesContour: Round, smooth no masses

or lesionsUmbilicus: Midline, inverted, no

discoloration or inflammationNumber of bowel sounds/minute: 10Abnormal sounds: NoMasses: NoOrganomegally: NoTenderness: No

• 2. Activity – Exercise Pattern:

• (A) Lung and Thorax:Respiration: 18 breath/minutes; relaxed,

regular, silent

Symmetrical Chest Movement: Yes

Lung Expansion: Symmetric bilateral with no lags in expansion

Breathing sounds: Bronchial (high pitched, loud amplitude: inspiration shorter than expiration) Bronchovesicular (moderate, mixed sound: inspiration equal to expiration) Vesicular (Low, soft, rusting sound: inspiration longer than expiration)

Adventitious sounds: No

• (B) Cardiovascular:Blood Pressure: 120/70 mmHgApical Pulse: 90 b/m short, gentle tapping,

full bounding, no bruitsPeripheral Pulses: All are present, +2,

irregular, and equal bilateralAbnormal Hear Sounds: No

• (C) Musculoskeletal:Temperomandibular Joint: No crepitating,

full ROM Neck Joint: full ROM, full resistance, non-

tenderUpper Extremities Joints: Right arm has

full ROM, left arm cannot be moved on his own

Lower Extremities Joints: Right leg has full ROM, left leg cannot be moved due to old stroke and femur neck fracture

Spine: Straight, no masses, normal curvation, full ROM (bending and rotation)

• 4. Cognitive-Perceptual Pattern:

• (A) Eyes: PERRLA• (B) Ears: Skin intact, no masses,

no tenderness or discharge, hearing whisper bilateral

• (C) Nose: No deformity, nares patent, no discharge, not tender

• (D) Mental Status:Can calculate, think abstractly, and

memory is good.• (E) Neurological Status:Has intact cranial nerves, However

due to old stroke the entire left side of body lacks sensory and motor function

MEDICATION PROFILEDrugs and Classification

For this patient Action/Indication

Dose/Route/Freq.

Contra-indication

Expected side effects

Nursing Implication

Clexane (anticoagulant)

Plasil (anti-emetic)

Pethidine (opoid agonist analgesic)

Prevent pulmonary embolism and DVT after hip surgery

Treat slow gastric emptying for diabetes

Relief of moderate to severe acute pain

1x1 – 40 mg SC

1x3 – 10 mg IV

1x4 – 75 mg IM

Hypersensitivity to enoxaparin, heparin, uncontrolled bleeding

History of hypersensitivity, GI bleeding, epilepsy

Diarrhea, bronchial asthma, COPD

Erythema at sites, fever, pain, chills

Restlessness, dizziness

Dizziness, insomnia, pruritis, nausea,

Teach patient and family to watch for signs of bleeding

Monitor blood pressure, give soft food

Monitor patients respiratory levels

Diagnostic EvaluationDate Test Performed Normal Value Patient Value Interpretation &

Nursing Implications

16-04-2011

Hematology Tests

CBC

CBC

CBC

CBC

CBC

Chemisty Tests

KFT

KFT

KFT

KFT

KFT

Hematocrit

Hemoglobin

WBC

Platelet

Lymphocyte

Na+

K+

Creatinine

Urea

Glucose

40 – 54%

13.2 – 16.2 gm/dL

4.1-10.9x10^3

140 – 450x10^3

20-50%

137-145 mEq/L

3.5-5.0 mEq/L

0.5-1.4 mg/dL

7-21 mg/dL

65-110 mg/dL

24.6%

8.36 gm/dL

12.3

186

23.7%

138 mEq/L

3.57 mEq/L

0.48 mg/dL

34 mg/dL

123 mg/dL

Low

Low

Leukocytosis

Normal

Normal

Normal

Normal

Normal

High – Uraemia

High – Sliding scale

Nursing Care PlanFunctional Health Pattern

Nursing diagnosis

Evidenced By/Defining Characteristics

Short Term Goals

Planned Intervention with rationale

Actual intervention

The Outcome with rationale

Cognitive/ Conceptual pattern

Acute pain related to trauma and muscle spasm

Verbalization and facial expression of discomfort and pain – says: “Pain is 6/10”

The client will report relief as evidenced by reduction in pain scale (0/10) and increased participation in activity by the end of my shift

•Position patient in proper alignment handle gently supporting leg with pillow to reduce pressure on nerves and tissues to reduce pain•Explain and demonstrate patient controlled analgesics giving the client control and decreasing fear

•Assisted patient by placing pillow underneath left leg

•Explained to patient that it is ok to ask nurse for analgesics if pain is too much to handle

Goal partially met, The patient’s pain has only slightly decreased – says: “pain is now 5/10 due to analgesics”

Other Possible Diagnosis:

• Activity intolerance related to trauma as evidenced by inability to perform activity of daily living

• Ulteration in bowel movement (constipation) related to … as evidenced by …

• Anxiety due to self-care deficit (elimination) related to prescribed activity restrictions

• High risk for impaired skin integrity related to immobility