Essential Nursing Care: Student Care Plan - Assignment Example

NSG1ENC – ESSENTIAL NURSING CARE Care Plan Patient John Ryan Patient UR: _____ Ward: Bed No Constipation Assessment Data: Subjective: Last defecated 4 days ago. Expresses pain in the abdominal and anal area when seated on the toilet. Normally defecates every two days. Objective: Observed grimacing during attempts at defecation; stool brown, dry and small; Inspection of abdomen – slightly distended. Auscultation - bowel sounds heard in all quadrants. Palpation – tenderness and pain in lower (L) quadrant and firm mass felt in descending colon. Problem/Nursing Diagnosis: Constipation in relation to insufficient physical activity secondary to neurological impairment Planning: Goals : John will not be constipated Short term goal: John will pass stool within the next 6-8 hours Long-term goal: John will be able to defecate every 2 days within the next 2 weeks following admission Expected Outcomes: John will be able to pass soft stool every 2 days John will not overly strain during defecation John will not feel pain during defecation John will drink atleast 1000 ml of water for the next 6-8 hours John will eat atleast four servings of fruits and vegetables daily John will be able to increase his mobility Interventions/Nursing Actions 1. Administer suppository Interventions/Nursing Actions 2. To assess causative/contributing factors Interventions/Nursing Actions 3. To assess current patterns of elimination (new medications, level of activity, diet, and similar activities which may affect usual patterns of elimination) Interventions/Nursing Actions 4. To facilitate return to usual and regular pattern of elimination Interventions/Nursing Actions 5. Assist John in getting to and from the commode during expected times of defecation. After ensuring his safety, close the bathroom door. If there may be times when John cannot be moved to the commode, privacy should still be provided to him while using the bedpan. Curtains and doors must be closed during defecation. Rationale To facilitate elimination of faeces; to soften stool and moisten the colon for easier and faster excretion (Funnell, Koutoukidis, & Lawrence, 2009) Rationale To determine factors in relation to diet or other activities which may have caused the constipation (Meiner & Lueckenotte, 2006) To address the cause of the problem and resolve it Rationale To determine changes in the regular patterns of elimination To determine if changes in elimination patterns may be caused by medication, by diminished activity, by diminished intake of fruits and vegetables (Timby, 2009) Rationale Instruct patient on increasing fibre in his diet to increase bulk and frequency of stool elimination (Grodner, Long, and DeYoung, 2004) Promote fluid (water and bulk-forming juices) intake to ensure formation of soft and moist stool (Wold, 2004) Increase mobility by assisting patient movements within his capability and as tolerated (Kyle, 2007) Instruct patient in following and sticking to regular patterns of elimination – following regular times in defecating (Mosby, 2010) Teaching family members on the following: the importance of John following regular patterns of elimination (including regular times in elimination); in preparing for John bulk-forming foods like fruits and vegetables; in ensuring that he drinks atleast 1000 to 1500 ml of water every day; and in assisting John in gaining and increasing mobility (Heath, 1995) Rationale To ensure that regular patterns of elimination are followed (Mosby, 2010) To provide privacy and to prevent embarrassment on John’s part. Lack of privacy during defecation can sometimes reduce or remove the urge to eliminate (Hoeman, 2007) Evaluation Assess elimination after administration of suppository/enema Observe stool elimination – times and patterns of elimination; including factors which may change or affect regular patterns of elimination Monitor his fruit and water intake – how much he takes and how well he likes taking them Monitor how much he knows about the importance of maintaining regular patterns of elimination and taking water and bulk-forming foods 2. Bedsores (pressure ulcers) Assessment Data: Subjective: Feels tenderness and mild pain in some parts of his back, most especially areas with bony protrusions Objective: Observed grimacing when kept in same position for prolonged periods; tenderness in some areas of his back Inspection of back – reddish parts on bony protrusions; moist skin due to perspiration, urine, and drainage Palpation – tenderness and mild pain in lower back, vicinity of hip area Problem/Nursing Diagnosis: Impaired tissue integrity related to impaired physical mobility secondary to prolonged pressure Planning: Goals : John will not develop pressure ulcers Short term goal: John will be kept dry and be moved side to side every two hours for the next 24 hours Long-term goal: John’s skin will be kept dry at all times; John will be moved side to side every two hours during the duration of his confinement Expected Outcomes: John’s risk for pressure ulcers would be eliminated John will not feel any tenderness at the bony protrusions at his back John will learn how to move from side to side at regular intervals John’s clothes and skin will be kept dry at all times John will increase his intake of fruits and vegetables Interventions/Nursing Actions 1. Frequent changes in positions; log-rolling every two hours (with assistance) Interventions/Nursing Actions 2. Teach the patient to use overhead handle bars in his bed to push himself up and down at regular intervals Interventions/Nursing Actions 3. Regularly check the patient’s clothes and skin for moisture; change clothes/linens regularly, especially if wet or dirty Interventions/Nursing Actions 4. Check the bed and the wheelchair for sufficient cushion and padding; add padding and cushions (pressure-relieving mats) on beds Interventions/Nursing Actions 5. Educate the patient and his family about keeping a healthy diet (high in protein, vitamins, and minerals) including adequate water and fluid intake Interventions/Nursing Actions 6. Regular daily monitoring of John’s skin integrity, especially in areas likely to develop pressure ulcers Rationale To relieve prolonged pressure (Smeltzer, et.al, 2008) To distribute pressure to different parts of the body (Smeltzer, et.al., 2008) To promote blood flow to the different parts of the body (Smeltzer, et.al., 2008) To help tissues recover from impact of pressure (Smeltzer, et.al., 2008) To increase and improve air flow into the back area and consequently promote dryness over said areas (Smeltzer, et.al., 2008) Rationale To relieve pressure and promote blood circulation Rationale To prevent softening of skin due to moisture (Collison, 2008) To prevent build-up of bacteria which can promote infection (Collison, 2008) Rationale To relieve and distribute pressure over areas likely to develop pressure ulcers (hip area, shoulder area, heels of the feet, and elbows (Nazarko, 2002) Rationale To ensure build-up of muscle mass; and prevention of weight loss (Derstine & Hargrove, 2000) To ensure that enough muscle and flesh covers bones and relieves pressure over skin (Derstine & Hargrove, 2000) To keep patient strong enough for increased mobility (Derstine & Hargrove, 2000) Rationale To ensure early prevention and treatment of pressure sores (Iyer, 2006) Evaluation Patient, with the help of his family maintains intact skin with no signs of redness or breaks over bony prominences in his body Manages to relieve and distribute pressure over bony protrusions Increases mobility (changes position every two hours) Gains some weight and builds muscle mass Keeps skin dry and clean 3. Risk for falls Assessment Data: Subjective: John expresses that he often feels weak and unable to balance his weight Fears that he would fall and injure himself every time he attempts to move Objective: Observed: limited mobility Inspection: weakness of muscles (legs and arms) Unsteady when attempting to walk or stand (with assistance) Difficulty during transfers from bed to wheelchair and vice versa Under medication: valium Spends little outside Needs assistance for mobility and during toileting Poor vision Problem/Nursing Diagnosis: Risk for falls related to impaired mobility secondary to neurological damage Planning: Goals : John will not experience any falls Short term goal: John’s risk for falls will be reduced by atleast 40% within the next 6-8 hours Long-term goal: John’s risk for falls will be reduced significantly or totally eliminated Expected Outcomes: John would increase his mobility without experiencing any falls John would spend more time outdoors John would gain more independence in his mobility John would be able to express less fears about falling There would be less difficulty in moving him from his bed to his wheelchair and vice versa Interventions/Nursing Actions 1. Refer John to a physiotherapist Interventions/Nursing Actions 2. Ensure that brakes on the bed are on at all times; ensure that guard rails on the bed are up especially when John is asleep; ensure that brakes on the wheelchair are on whenever John is being moved from the bed to the wheelchair and vice versa Interventions/Nursing Actions 3. Ask attending physician to review John’s medication into other less sedating medications Interventions/Nursing Actions 4. Consult with physician for ways to possibly increase in Vitamin D (Vitamin D supplements; exposure to sunlight atleast 2-4 hours each day—preferable before 10am or after 2pm) Interventions/Nursing Actions 5. Ensure that the room is free of clutter, wires, and other barriers which may cause falls; that floor is not slippery; carpets and mats are secure and immobile; and secure slip-free rubber mats on bathroom floors Rationale To instruct patient on the safe and proper ways to attain and increase mobility (Healey, et.al., 2004) To help patient attain independence and confidence in his movements and activities To exercise John’s muscles and regain mobility Rationale To prevent shifting of beds/wheelchair while patient is being moved Rationale To increase alertness and prevent compromised levels of consciousness caused by side-effects of medications (Spittler, 2009) Rationale Vitamin D improves musculoskeletal function and improves quadriceps strength (Langley-Evans, 2009) To prevent exposure to harmful UV rays of the sun (Women’s Fitness, 2010) Rationale Remove barriers which may trip the patient (Joint Commission Resources, 2010) To ensure environmental safety (Joint Commission Resources, 2010) To make it easy for John to navigate floors (Joint Commission Resources, 2010) To prevent slips Evaluation Patient would express no fear of falling Patient would spend more time outside Patient’s home and hospital room free from clutter; bathroom floor is slip-free 4. Impaired ability to perform activities of daily living Assessment Data: Subjective: John expressed that he has difficulty performing his daily grooming activities like grooming, dressing, bathing, and making it to and from the bathroom Objective: Inability to get bathroom supplies, wash body parts, to get in and out of bath Needs assistance in changing clothes Inability to get in and out of commode Problem/Nursing Diagnosis: Impaired ability to perform activities of daily living Planning: Goals : John will be able to regain the ability to perform his daily activities independently Short term goal: John would be able to put on his shirt, comb his hair, and brush his teeth on his own without assistance after 8 hours of nursing interventions Long-term goal: John would be able to increase independence in the conduct of his daily activities Expected Outcomes: John would be able to perform most of his daily activities independently John would be able to get in and out of commode independently John would be able to improve his self-esteem because he will be able to reduce his dependence on other people Interventions/Nursing Actions 1. Refer John to an occupational therapist Interventions/Nursing Actions 2. Perform activities of daily living with patient based on the teachings of the occupational therapist Interventions/Nursing Actions 3. Client education Interventions/Nursing Actions 4. To teach the members of the family on how they can help John in his activities and to attain independence in said activities Rationale To teach John how to conduct his daily activities safely and independently (Law, Baum, & Dunn, 2005) To teach John techniques on how to bathe, groom, and clothe himself despite his limited mobility (Law, Baum, & Dunn, 2005) Rationale To help John get used to these activities and to ensure that they eventually become easier to perform (Schultz & Videbeck, 2009) Rationale To teach John how to modifying his behaviour and to accept the adjustments he has to make in his activities in order to ensure proper functioning (Daniels, 2004) Rationale To ensure that John would not be too dependent on his family for his daily activities (Daniels, 2004) To ensure that John would not injure himself during these activities (Daniels, 2004) Evaluation John is able to groom, bathe, and clothe himself John’s family is able to assist him in his activities and to ensure that he does not injure himself during these activities John is able to get in and out of the commode on his own John is able to conduct his daily activities with minimal supervision and assistance Works Cited Collison, D. (2008) Pressure Sores. Merck.com. Retrieved 07 October 2010 from http://www.merck.com/mmhe/sec18/ch205/ch205a.html Daniels, R. (2004) Nursing fundamentals: caring & clinical decision making, New York: Thomson Delmar Learning Derstine, J. & Hargrove, S. (2000) Comprehensive rehabilitation nursing. USA: Saunders Funnell, R., Koutoukidis, G., & Lawrence, K. (2009) Tabbners Nursing Care: Theory and Practice. New South Wales: Elsevier Health Sciences Gordon, M. (2010) Manual of Nursing Diagnosis. New York: Jones & Bartlett Green, K. (1998) Home care survival guide. Pennsylvania: Lippincott Williams & Wilkins Grodner, M. & Long, S. & DeYoung, S. (2004) Foundations and clinical applications of nutrition: a nursing approach. Missouri: Mosby Healey, F., Monro, A., Cockram, A., Adams, V., Helestine, D. (2004) Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. Age and Ageing Advance Access. Retrieved 07 October 2010 from http://ageing.oxfordjournals.org/content/early/2004/05/19/ageing.afh130.full.pdf Heath, H. (1995) Potter and Perrys foundations in nursing theory and practice. Missouri: Mosby Hoeman, S. (2008) Rehabilitation nursing: prevention, intervention and outcomes. Missouri: Mosby Iyer, P. (2006) Nursing home litigation: investigation and case preparation. Arizona: Lawyers and Judges Publishing Company Joint Commission Resources (2005) Reducing the risk of falls in your health care organization. USA: Joint Commission Resources, Inc. Kyle, G. (2007) Fact file: A guide to managing constipation: part two. Nursing Times. Retrieved 07 October 2010 from http://www.nursingtimes.net/nursing-practice-clinical-research/fact-file-a-guide-to-managing-constipation-part-two/199200.article Langley-Evans, S. (2009) Nutrition: a lifespan approach. Massachusetts: John Wiley & Sons Law, M., Baum, C., Dunn, W. (2005) Measuring occupational performance: supporting best practice in occupational therapy. New York: Slack Incorporated Meiner, S. & Lueckenotte, A. (2006) Gerontologic nursing. New South Wales: Elsevier Health Sciences Nazarko, L. (2002) Nursing in care homes. Melbourne: Blackwell Publishing Nursing Diagnosis: Constipation (2010) Mosby Elsevier. Retrieved 07 October 2010 from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=13 Schultz, J. & Videbeck, S. (2009) Lippincotts Manual of Psychiatric Nursing Care Plans. Massachusetts: Lippincott Williams & Wilkins Smeltzer, S., Bare, B., Hinkle, J. & Chhver, K. (2008) Brunner and Suddarths textbook of medical-surgical nursing. Pennsylvania: Lippincott Williams & Wilkins Spittler, K. (2009) Use of Sedative Hypnotics May Increase Risk of Falls and Fractures. Neurology Reviews. Retrieved 07 October 2010 from http://www.neurologyreviews.com/09sep/A2%20hypnotics.html Timby, B. (2009) Fundamental Nursing Skills and Concepts. Philadelphia: Lippincott Williams & Wilkins Vitamin D Recommendation for Stronger Bones (2010) Women’s Fitness. Retrieved 07 October 2010 from http://www.womenfitness.net/stronger-bones.htm White, L. (2005) Foundations of Nursing. New York: Thomson Delmar Learning Wold, G. (2004) Basic geriatric nursing. Missouri: Mosby Read More