1RUNNING HEAD: CAREPLAN

Nursing 201 Care Plan

Elizabeth Coughlin

Bucks County Community College

Section 1B

Mrs. Lori Ischinger, MSN, RN

2Care Plan

Table of Contents

Abstract 3

Assessment 4

Pathophysiology 4

FHP Analysis 5-9

Nursing Diagnosis 9

Planning 10

Implementation 10-16

Evaluation 16-17

Appendix A 18-19

References 20

Appendix B Attached

3Care Plan

Abstract

The purpose of this paper is to develop a patient care plan by utilizing the nursing

process, completing a physical assessment, and interviewing the patient. All interactions in this

paper took place at Abington Memorial Hospital between a patient and nursing student.

4Care Plan

Assessment

The student nurse began by receiving report during shift change. During report she was

able to gather some data and background information regarding her patient. The patient, ND, is

a 81 year old male that arrived on October 24, 2015 following a cerebral vascular accident. The

patient has a past medical history of chronic hypertension, hyperlipidemia, aortic aneurysm

w/o rupture of unspecified site, and dementia w/o behavioral disturbances. ND is 6.0 feet and

156 lbs. ND is drinking thickened liquids and following an ADA diet following the new diagnosis

of diabetes mellitus. An allergy assessment revealed reactions to the following medications,

morphine, penicillin, and sulfa drugs. ND had vital signs all WNL, Temperature 97.3, Blood

pressure 110/70, pulse 72, pulse ox was 96 on RA, and respirations were 18. His morning blood

glucose level was 175. The neurological assessment showed normal papillary response and

size, both eyes were 3mm, round, and brisk. His muscle strength was strong in all extremities

and he made purposeful movements. ND had a glasgow coma score of 14 where he only lost

one point for confusion.

Pathophysiology

ND had an admitting diagnosis of a cerebral vascular accident. According to an article on

strokecenter.org a stroke is, “the sudden onset of weakness, numbness, paralysis, slurred

speech, aphasia, problems with vision and other manifestations of a sudden interruption of

blood flow to a particular area of the brain. The ischemic area involved determines the type of

focal deficit that is seen in the patient.”

5Care Plan

Health Perception and Management Pattern

The student nurse asked ND questions regarding his health maintenance and patterns,

however he was confused and so information was not accurate. He told the student nurse he

lived at home with his wife and he thought he drove himself to the hospital. He could not

remember the events that took place leading up to his admittance to the hospital. The student

nurse later learned ND was brought to the hospital from Garden Springs where the care team

noticed ND having trouble speaking and dressing. ND had been at AMH for 10 days and the plan

was to discharge him back to Garden Springs later that day. ND general appearance was

unkempt, however he was in the hospital for 10 days and was not able to perform his usual

ADLs that he normally would perform at home. ND denies recently smoking, and claims to have

quit more than 10 years ago and used to drink socially. A chest x-ray showed cardiomegaly and

an ECG revealed A Fib with rapid ventricular responses and a right bundle branch block. ND

denies using any alternative treatment programs or supplements.

Nursing Diagnosis

Decreased cardiac output related to A-fib as evidenced by abnormal ECG.

Nutrition

ND had an appetite and didn’t notice any changes; he ate 75 percent of his breakfast

and 90 percent of his lunch. He denies any significant weight change in the past few months.

ND is on thickened liquids due to difficulty swallowing thin liquids. ND did not wear dentures

and had some missing teeth, but no loose or chipped teeth. All ND electrolyte labs were WNL.

6Care Plan

ND had a slightly lower albumin level of 3.0, and increased glucose of 175. His skin was pallor,

dry, flaky, and warm. He had bilateral +1 edema in ankles and feet, ecchymosis on his arms

most likely from previous IV site, and a (raised) rash covering his back. All of his skin was intact

and there were no pressure ulcers present. His capillary refill was greater than 3 seconds (4

seconds) on his toes. His lips were pink and moist and oral mucosa was moist and pink as well.

Nursing Diagnosis

Decreased tissue perfusion related to disease process as evidenced by capillary refill greater

than 3 seconds.

Elimination Pattern

ND has an indwelling catheter that was inserted on 10/26, despite having the catheter he is still

retaining urine and having suprapubic pain when moving and with palpation. A bladder scan

revealed 111 ml of urine in the bladder. His last BM was 11-1, he did not have GI any

complaints, and he had bowel sounds in all 4 quadrants. His abdomen was round, distended,

and tender. Bun and creatinine were WNL.

Nursing diagnosis

Pain related to bladder spasms as evidenced by retained urine and patient jumping and

grimacing in pain.

7Care Plan

Activity Pattern

ND needed assistance from one person to perform ADLs. Upon discharge he will need

assistance with his care, but he will receive that from Garden Springs. He is able to walk with a

walker. He has dyspnea on exertion, and will require daily ROM to maintain adequate motor

function. ND had a irregular heart beat and distended neck veins. The student nurse was able to

palpate radial pulses, but not dorsalis pedis. The student nurse obtained a Doppler to locate

pedal pulses; the right pedal pulse was difficult to locate with the Doppler. ND had easy, but

shallow respirations, his chest was symmetrical, no cough, and his lungs were clear. His lab

results showed low RBC (3.71) and H+H (10.6& 34.9%). WBC and platelets were WNL.

Nursing diagnosis

Activity intolerance related to the disease process as evidenced by dyspnea on exertion.

Risk for falls related to unsteady gait

Sleep Rest Pattern

ND stated he did not have any trouble falling asleep, staying asleep, and he sleeps at least 8

hours a night. He does not take any naps or use sleep aids. He watches TV to relax before he

goes to bed.

Nursing Diagnosis

Risk for disturbed sleep pattern related to frequent care during hospital stay.

8Care Plan

Cognitive Pattern

ND was awake and alert, but he was not oriented to time and place. His hearing was normal

and he wore eyeglasses that were at his bedside. His speech was slightly slurred, but his

language was appropriate and logical. A pain assessment revealed he had an aching pain 8/10

in the suprapubic region with movement and palpation. He expressed his pain by jumping and

grimacing when palpated. ND was given a B&O suppository to help relieve bladder spasms and

decrease the pain.

Nursing Diagnosis

Pain related to bladder spasms and retained urine as evidenced by jumping and grimacing

when palpated as well as the patient complaints.

Self Perception Pattern

ND seemed hopeful for a good prognosis and was calm and cooperative for the student nurse.

He showed anxiety about the pain and he stated he did not want to go home until someone

relieves the pain. He was willing to comply to all treatments and procedures and his only

concern was the suprapubic pain.

Nursing Diagnosis

Anxiety related to going home with pain as evidenced by patient stating, “I don’t want to go

home with this pain, please figure out what this pain is. I can’t go home like this.”

9Care Plan

Role Relationship Pattern

ND is married and has four girls that are grown, but lives at Garden Springs. He is a retired

mechanical draftsman. ND was a little disoriented and this information was difficult to assess.

His Erikson stage would be integrity vs. despair. He didn’t seem to have many worries and he

talked happily about his family. He didn’t seem to want to go into detail about his work and

kind of brushed off the conversation.

Nursing Diagnosis

Altered family process related to disease process as evidenced by needing to move to LTC

facility.

Coping/ Stress Pattern

ND was afraid of going home with pain in his abdomen. He was very accepting, calm and

cooperative with procedures and treatments.

Nursing Diagnosis

Fear related to going home with unresolved pain as evidenced by patient stating he was

worried about going home with pain.

Value Belief Pattern

ND was Lutheran and did not have any requests to meet his religious needs. He did not specify

and restrictions of conflicts with regards to religion and treatments. He is not an organ donor.

Nursing Diagnosis

10Care Plan

Risk for impaired religiosity related to aging

Nursing Diagnosis

Knowledge deficit related to the disease process of diabetes as evidenced by

uncontrolled blood glucose levels and recent diagnosis.

Planning

Due to ND’s recent diagnosis of diabetes he will need extensive teaching about the

disease process and how to prevent further damage and complications to the body. He will

need to adjust to many diet and exercise changes in order to maintain lower blood glucose.

Interventions

Short Term Goal: At 7 am the patient will select appropriate breakfast food following a ADA

diet

1. The student nurse will teach carbohydrate counting to ND; he can have 45-60 grams of

carbohydrate at a meal. The quickest way to count carbs is by looking at the food labels and

looking at the total grams of carbohydrate. Many fresh foods don’t have labels so the student

nurse will give ND a guide.

For example there is about 15 grams of carbohydrate in:

1 small piece of fresh fruit (4 oz)

11Care Plan

1/2 cup of canned or frozen fruit

1 slice of bread (1 oz) or 1 (6 inch) tortilla

1/2 cup of oatmeal

1/3 cup of pasta or rice 4-6 crackers

1/2 English muffin or hamburger bun

1/2 cup of black beans or starchy vegetable

1/4 of a large baked potato (3 oz)

2 Tbsp light syrup 6 chicken nuggets

1/2 cup of casserole

1 cup of soup

1/4 serving of a medium French fry

Rational: “Carbohydrate counting in=s a meal planning technique used to keep track of the

amount of carbohydrate eaten with each meal and per day. Often patients are advised to limit

carbohydrates to a predetermined number.”(Lewis 1167) By tracking and limiting

carbohydrates patients are able to maintain normal blood glucose levels more efficiently.

2. The student nurse will teach ND how to use create my plate app to follow a diabetic diet. The

student nurse will encourage fresh fruit to help satisfy sweet cravings and she will teach ND to

avoid sweetened drinks such as soda.

12Care Plan

Rational: “This simple method helps the patient visualize the amount or vegetables, starch, and

meat that should fill a 9 in plate.” (Lewis 1167)

3. The student nurse will teach the patient to limit alcohol consumption, one drink a day for

women and two drinks per day for men. The student nurse will explain that alcohol should be

consumed with food and recommend using sugar free mixes and drinking dry, light wines.

Rational: “Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver.

This can cause severe hypoglycemia in patients on insulin or oral hypoglycemic medications

that increase insulin secretion.” “Alcohol should be taken with food to reduce risk of nocturnal

hypoglycemia.” “Carbohydrate taken with the alcohol (mixed drink) may raise blood glucose.”

(Lewis 1166)

Short Term Goal: At 7pm the patient will demonstrate proper technique to monitor blood

glucose

1. The student nurse will teach proper hand washing during Am care and before lunch

Proper Hand Washing

1. Turn on water

2. Soap your hands and scrub for 20 seconds making sure to get in the webbing and under nails.

3. Rinse hands

4. Dry hands

5. Take towel and turn off tap

13Care Plan

Rational: “A patient with diabetes is more susceptible to infection because of a defect in the

mobilization of white blood cells and impaired phagocytosis by neutrophils and monocytes.”

(Lewis)

2. The student nurse will perform a morning blood glucose and afternoon blood glucose to

prepare the patient to be able to demonstrate self monitoring. The student nurse will explain

the steps of the process and provide written steps with pictures for the patient to review.

Self monitoring Steps

1. Wash hands

2. Place the lancet in the penlet lancing device

3. Use the side of the finger pad to obtain blood sample. (There are fewer nerves along the

side)

4. Set penlet device to make sure puncture is deep enough, but not too deep that it causes pain

and bruising.

5. Obtain sample and follow monitor instructions

6. Record results and compare with personal target blood glucose goals.

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14Care Plan

Rational: Self monitoring is a critical part of diabetes management. By providing a current blood

glucose reading, SMBG enables the patient to make decisions regarding food intake, activity

patterns, and medication dosages. It also produces accurate records of daily glucose

fluctuations and trends, and it alerts the patient to acute episodes of hyperglycemia and

hypoglycemia.”(Lewis 1168)

3. The student nurse will teach hypoglycemia and hyperglycemia symptoms

Hypoglycemia

Confusion Dizziness

Feeling shaky Hunger

Headaches Irritability

Pounding heart; racing pulse Pale skin

Sweating Trembling

Weakness Anxiety

15Care Plan

Hyperglycemia

Increased thirst Headaches

Trouble concentrating Blurred vision

Frequent peeing Fatigue (weak, tired feeling)

Weight loss Blood sugar more than 180 mg/dL

Rational: The patient should be aware of these symptoms to prevent acute complications of DM. “Acute complications arise from hyperglycemia and hypoglycemia. It is important for the health care provider to distinguish between hyperglycemia and hypoglycemia because hypoglycemia worsens rapidly and constitutes a serious threat if action is not immediately taken.”(Lewis 1174)

Long Term Goal: The patient will have an A1C less than 8% at next doctor appointment

1. The Student nurse will teach the patient to self administer insulin injections.

1. Wash hands thoroughly

2. Inspect insulin bottle before using it, proper type, concentration, and expiration date.

3. If cloudy gently roll the insulin in the palms of hands to mix solution

4. Select proper injection site, back of arms, abdomen, buttocks, or thighs.

5. Clense skin with soap or alcohol

6. Pinch up skin and push needle straight in, if thin or using 5/16 needle you may need to use 45

degree angle.

7. Let go of skin, leave needle in place for 5 seconds to ensure all insulin has been injected.

16Care Plan

8. Destroy and dispose of single use syringe safely.

Rational: The steps to administration should be taught to new insulin users and reviewed with

patients already using insulin. “Never assume that because the patient already uses insulin, he

or she knows the proper technique. The patient may not have understood prior instructions, or

changes in eyesight may result in inaccurate preparation.”(Lewis 1160)

2. The student nurse will teach the patient how to maintain an exercise program. There are

many activities that are beneficial for health promotion. It is important to choose activities that

are enjoyable for the patient to increase the

success of the exercise program.

Rational: “Regular, consistent exercise is an

essential part of diabetes and pre-diabetes

management. The ADA recommends that people

with diabetes perform at least 150 min/wk (30 minutes, 5 days/wk) of moderate-intensity

aerobic physical activity.” (Lewis1167)

3. The student nurse will instruct the patient to carry medical identification at all times so

inform others that he or she has diabetes in case of an emergency. Also if traveling teach the

17Care Plan

patient to get up at least every two hours special arrangements for needles and snacks may be

needed if traveling by plane.

Rational: “Police, paramedics, and many private citizens are aware of the need to look for this

identification when working with sick or unconscious persons. An identification card can supply

valuable information, such as the name of the health care provider; the type of diabetes; and

the type and dosage of insulin, noninsulin injectable agents, or OAs.”(Lewis 1173)

Evaluation

ND was able to meet his first goal of choosing appropriate breakfast selections, such as an

whole wheat English muffin, an apple, and coffee. He was able to count this as 45 carbs using

the chart the student nurse provided, 30 carbs for the entire English muffin and 15 for the fresh

fruit. The interventions for this goal were appropriate and were efficient in meeting the goal.

ND was able to meet his second goal of self monitoring his blood glucose. He understood the

need for hand washing first, to prevent infection. The pictures and two prior demonstrations

were helpful in meeting the goals in a reasonable time. The long term goal will be assed at a

later time. The student nurse is hopeful that if the patient is compliant with the diet, exercise,

and medication programs then he will meet his goal of having an A1C less than 8%. The A1C

test will be helpful in determining whether or not the patient has been compliant with the

guidelines put in place. If the patient has not been compliant the programs will have to be

revaluated and changes may need to take place.

18Care Plan

Appendix A

Medications

Insulin aspart- NovoLOG

Class- Pancreatics

Indication- control of hyperglycemia in patients with type 1 or 2 diabetes mellitus.

Action- Lowers blood glucose by stimulating uptake in skeletal muscle and fat, inhibiting hepatic

glucose production.

Dose depends on blood glucose, response, and many other factors.

Dose for ND- 6 units SC AC

Side effects- hypoglycemia, erythema, pruritis, swelling, anaphylaxis.

*Before administering assess for hypoglycemia, monitor body weight periodically, assess for

allergies, and monitor blood glucose q 6hr during therapy. Double check doses and orders and

check expiration date.

Heparin

Antithrombotics

Indication- Prophylaxis and treatment of thromboembolic disorders including venous

thromboembolism, pulmonary emboli, a-fib, with embolization, acute and chronic consumotive

coagulopathies, peripheral arterial thromboembolism.

19Care Plan

Side effects- drug induced hepatitis, alopecia, rashes, urticaria, bleeding, HIT, anemia.

Dose- subcut, 5000 units every 8-12 hours

ND Dose- 5000 units every 8 hours

Atorvastatin- HMG-CoA reductase inhibitors

Indication- adjunctive mgt of primary hypercholesterolemia and mixed dyslipidemias. Primary

prevention of cardiovascular disease.

Side effects- dizziness HA, insomnia, weakness, chest pain, peripheral edema, blurred vision,

constipation, nausea, diarrhea, bronchitis, rashes, pruritus, myalgia, arthritis, ED,

Rhabdomyolysis.

Dose- 10-20 mg once daily

ND Dose- 20 mg daily

Metroplol -Beta Blocker

Indication: Treats HTN, angina, prevent MI, and MGT of HF*

Action: Blocks stimulation of beta 1 adgenergic receptors

Desired Effects: Decreases BP and HR

S/E Bradycardia, hypotension, HF, pulmonary edema, fatigue, bronchospasm, and decreased

libido.

20Care Plan

Before administration monitor BP and HR do not give if systolic is less that 100 or HR less than

60. Monitor daily weights.

B&O Suppository- Belladonna alkaloid and opium

Treats moderate to severe pain due to spasm of urinary tract

Anticholinergic and analgesic combination relaxes smooth muscles of urinary tract and relieves

pain.

S/E: blurred vision, constipation, dry mouth, difficulty urinating, fast pulse, and vomiting.

Diltiazem- calcium channel blocker

Indication: HTN, angina, prinzmetals angina, supraventricular tachyarrhythmias

Action: inhibits transport of Ca into myocardial and vascular smooth muscle cells resulting in

inhibition of excitation, contraction coupling, and subsequent contractions.

S/E anxiety, arrhythmias, HF, bradycardia, hypotension, peripheral edema, tachycardia, syncope

Monitor BP, HR, K levels, liver and renal functions. Do not give if systolic BP is less than 100 and

HR less than 60

21Care Plan

Refrences

Vallerand, April Sanoski, Cynthia. (2013) Davis’s Drug Guide for Nurses Thirteenth Edition. F.A.

Davis Company.

Berman. A., Snyder.S.( 2012) Fundamentals of Nursing Concepts, Process, and Practice

Pearson Education, INC.

Lewis. (2014) Medical surgical nursing Assessment and Management of Clinical Problems Ninth

Edition. Elsevier.

Web MD. 2015. Hyperglycemia and Diabetes.

-****-http://www.webmd.com/diabetes/guide/diabetes-hyperglycemia