AMERICARE

INSTITUTE

The Nursing Care Plan flows from the Nursing Process. “The Nursing Process is an
approach for selecting, organizing, and delivering appropriate nursing care to
patients. The Nursing Process is one variation of scientific reasoning that allows
students to organize care for patients, including individuals, family, or community”
(Potter & Perry, 2007, p. 99).

The Nursing Care Plan includes:

Data Collection: All subjective and objective data collected regarding the client;
from all sources—interview, client record, literature, health history, physical
examination, observation of client’s behavior, diagnostic and laboratory data.

Nursing diagnosis: Using the NANDA International the student will choose the
nursing diagnosis that best matches the data collected regarding a client’s particular
(see pp. 109-110, Potter & Perry).

Plan: Set goals for client care, state desired outcomes for each intervention and for
client, identify appropriate nursing actions.

Implementation: Perform the actual nursing actions identified in planning.

Progress: Determine if set goals were met and outcomes achieved.

BEGIN THE PROCESS AGAIN IF NEED BE.

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NURSING CARE PLAN- Kindred Lake Shore Hospital- Fundamentals

Student Name ionela luna Date11/08/2009

Care Plan Number 3 Instructor Mary Soeding

Client Initials J.A. DOB 03.18.1957 Age 52 Room #303

Medical Diagnosis/es: Open wound site; DM; encephalopathy; CVA;

Hypothyroidism; Seizures.

ETIOLOGY: Open wound site: A wound is type of physical trauma where in the
skin is torn, cut or punctures (an open wound), or where blunt force trauma causes
contusion( a closed wound)

Diabetes mellitus: is a condition in which the body wither does not produce enough,
or does not properly respond to insulin a hormone produce in the pancreas. Insulin
enables cells to absorb glucose in order to turn it into energy. In diabetes, the body
either fails to properly respond to its own insulin, does not make enough insulin, or
both. This causes glucose to accumulate in the blood, often leading to various
complications.

Encephalopathy: in modern usage, encephalopathy does not refer to a single disease,

but rather to a syndrome of global brain dysfunction; this syndrome can be caused
by many different illnesses. In some contexts it refers to permanent brain injury,
and in others it is reversible. It can be due to direct injury to the brain, or illness
remote from the brain. In medical jargon it can refer to a wide variety of brain
disorders with very different etiologies, prognoses and implication.

Hypothyroidism: Is the disease state in humans caused by insufficient production of

thyroid hormone by the thyroid gland.

CVA: Cerebral Vascular Accident is the rapidly developing loss of brain function
due to disturbance in the blood supply to the brain, this can be due to ischemia(lack
of glucose and oxygen supply) caused by thrombosis or embolism or due to a
hemorrhage. As a result, the affected area of the brain is unable to function, leading
to inability to move one or more limbs on one side of the body, inability to
understand or formulate speech, or inability to see one side of the visual field.

Seizures: is a sudden surge of electrical activity in the brain that usually affects how
a person feels or acts for a shot time. Some seizures are hardly notice- perhaps a
feeling or “pins and needles” in one thumb for a few seconds. During other seizures,
the person may become unconscious; fall to the floor, and jerk violently of several
minutes. Between these extremes is an astonishing range of feeling and actions.

Tracheotomy: Surgical procedure of the neck to open a direct airway through an

incision in the trachea. May be performed for a variety of reasons including: tx of

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lung injuries caused by pneumonia, severe acute respiratory distress syndrome,
injury from mechanical ventilation, pulmonary aspiration.

Medical History: (Make sure you put in age, race and sex here as well as any drug
allergies and what bugs they may have)
The patient is a 52 –year old African American female with past medical history
significant for stroke, chronic encephalopathy, seizures, hypothyroidism who was
transferred from an acute care facility, where she presented from the nursing home
with abnormal labs. She was found to have a high white count, low hemoglobin and
hematocrit, and was found to be septic with pneumonia, urinary tract infection. She
had a chronic tracheostomy. During hospital course, she was put on the ventilator
support. Pulmonary services are consulted. She was managed with IV antibiotics as
infectious disease recommendation. Unfortunately records are somewhat sketchy
from the south shore hospital, but she able to be weaned off from ventilator and was
kept on a trach collar.

Diagnostic Tests: (Labs, Imaging and etc)

WBC count 14.4-high( indicative of infection), normal range 4.0-10.5
RBC count 3.41 low ( anemia, blood loss) normal range 3.80-5.10
Hgb 10.3 low( anemia, changes in iron and vit B12 absorption due to aging)-normal
range 11.5-15.0
Hct 31.2 low( acute blood loss; chronic iron deficient); normal 34.0-44.0
RDW15.4% high(mixed population of RBCs; immature RBCs tend to be
larger);normal 11.7-15.0
Blood count plt automated 673high(a high platelet count can signal a more serious
blood problem known as a myeloproliferativ) ;normal range 140-415
Monocytes 3% low(can occur in response to the release of toxins into the blood by
certain types of bacteria) ;normal 14-46

Objective Data: (VS, Head to Toe Physical Assessment)

Vitals: T: 97.8 BP:147/75 P: 75-88 R:20

Neuro/sensory: patient nonverbal. She does not track. Does not follow command.
Her pupils are equal and reactive. Conjunctivae pink; sclera anicteric

CV:heart sounds regular without gallops or murmur . radial pulse normal on left
side

Respiratory: the patient is currently on T-piece. Lungs: bilateral breath

sound with scattered rhonchi
Resp rate normal 20

GI: abdomen-soft, nontender, g-tube was noted to be in place(diet glucerna 1.2 rate
75ml/hr), g-tube site is clean. Bowel sounds are positive.

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GU: incontinent of bladder. Foley catheter present. At time of assessment 150 ml of
clear yellow urine in bag.

Skin: patient has a rough skin especially at the lower extremities; stage IV ulcer at
the sacral area with some necrotic tissues and underwent a debridement.

Musculo-sketal: contractures are noted in the upper extremities, right arm weak
and flaccid. She has no peripheral edema, extremities atrophic.

Psychosocial: the patient is nonverbal, does not follow commands and does not
appeared to be in any apparent distress at present time.

Subjective Data: (What the patient reports).patient is nonverbal, no distress, the

patient is lying confrtably

NANDA NURSING DIAGNOSIS/ES (no less than 2)

1.Skin integrity ,impaired: risk for pressure sore; pressure ulcers; bed sores;
decubitus care
Risk factors: extreme of age, immobility, mechanical forces(pressure, shear,
friction), pronounced bony prominences, poor circulation, incontinence

2.Aspiration, risk for

Risk factors; reduced level of consciousness, depressed cough and gag reflex,
presence of tracheotomy and gastrointestinal tube, impaired swallowing

3.Communication, impaired verbal

Brain injury that adversely affects the transmission, reception or interpretation of
language or other forms of communication; Structural problem such as
tracheostomy; patient has sensory challenge involving hearing or vision,

PLAN—State your priorities for each planned activity. What are your
goals and expected outcomes for each goal?

Skin integrity – patient will be adequately bathed

Lines will be changed in a timely manner
Proper care will be given
Assess for environmental moisture( wound drainage, high humidity)
Asses surface that patient spends majority of time on( mattress for bedridden
patient) Reassess skin often and whenever the patient’s condition of treatment plan
result in an increased number of risk factors
2.Aspiration
Asses cough and gag refelex
Auscultate bowel sounds to evaluate bowel motility
Asses pulomanry status for clinical evidence of aspiration. Auscultate breath sounds
for development of cracklesor rhonchi
In patient with tracheostomy tubes, monitor the effectiveness of the cuff.
Collaborate with the respiratory therapist, as needed, to determine cuff pressure

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3.Imparired communication
Patient will demonstrate understanding even if not able to speak
Patient will use effective alternative communication techniques

IMPLEMENTATION—What interventions will you employ (P &, p.119)

1.Skin integrity- maintain or teach asepsis for dressing changes and wound care,
catheter care and handling; wash hands; perform head to toe skin assessment; avoid
positioning patient on sites of skin impairment; frequent repositioning every 2
hours.
2.Aspiration- proper position to decrease risk for aspiration; provide oral care after
meals; check placement before feeding; supervise or assist patient with oral intake;
position patients who have a decreased level of counsciousness on their side.
3.Impaired communication. Speak slowly and clear; explain all procedures and care
to the patient; maintain eye contact with patient

Summary of Medications:

1) Medication (Name & Class): PANTOPRAZOLE/ protoxin, protoxin IV

Func cl: proton pump inhibitor
Action: blocks final step of acid production
Uses: gastroesppheagel reflux disease
Dosage R: GERD adult PO 40mg/day* 8 wk
Side ef: headache, insomnia, diarrhea, abd pain, hyperglycemia

2) Medication (Name & Class): aspirine

Nonopioid analgesic, nonsteroidal anti-inflammatory, antipyretic, antiplatelet

Action: blocks pain impulses to cns, reduce inflammation by inhibition of

prostaglandin synthesis; antipyretic action results from vasodilatation of peripheral
vessels
Uses: mild to moderate pain or fever includingRA, osteoarthritis, thromboembolic
disorders: TIA, ischemic stroke
Dosage and route : adult :po 2.6-5.2g/ dfay in divided doses q4-6h
Side effects: stimulation, deowsiness, dizziness, confusion, headache, rapid pulse,
pulmonary edema, rash.

3) Medication (Name & Class):ferrous sulfate

Hematinic; iron preparation.
Action: replace iron stores needed for rbc dev, energy and O2 transport
Uses: iron dificinecy anemia, prophylaxis for iron deficiency in pregnancy
Dosage and routes: adult po 50-100mg tid ; child 2-12 yr po 3 mg/kg/day
Side effects; nausea, constipation, epigastric pain, black and tarry stools, temporary
discolored tooh enamel and eyes

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