Practical Nursing Humber ITAL Mini Care Plan

Step 1 Analysis
Student Name: Date:
Week:
Client Age
Living
Diet
Activity
Diagnosis Problem
s
Accommodati
Level
Initials
on
Stroke, Dimentia
Long-Term Care
Regular
Low
T.C
72
Step 1 Assessment All Modes
Adaptive/
Ineffectiv
e
Physiological (all systems)
+/Problem
Ventilation
Diagnosis:
None
History:
None
Lifestyle:
None
Assessments:
O2Sat: 97%
R: 20
Rhythm: Steady
Breathing effort: Relaxed
Inspection:
Cough: no
Sputum: None
Symmetrical expansion: Yes
Auscultation:
Breath sounds:
o Bronchial: Present
o Vesicular: Present
o Bronchial Vesicular:
Present
Crackles: No
Wheezes: No
Medications:
None
Lab Values:
Total CO2:30 mmol/L
Cardiovascular
Diagnosis:
Stroke
History:
None
Lifestyle:

+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+

-Pt is at risk for recurrent

stroke, DVP, bedsores,
depression and decreased
swallowing ability.

- smoker: No
- Alcohol: No
Assessments:
P: 80 b/min and regular
BP: 123/87
O2Sat: 98%
on room air
Capillary refill: less than 2
seconds
Inspection:
Skin color: Brown
Nail beds: pink
No pallor
No abnormal pulsations visible
on pericardium: yes
Auscultation:
S1 & S2 identified: yes
No murmurs
Palpation:
Pulses palpable:
o Dorsalis pedis: yes
o Radial : yes
Edema: legs
Medications:
-Indapimide
-perindopril
-Amoldipine
Lab Values:
Troponin: 0.02 ug/L
CK: N/A
CKMB: N/A
PTT: 24 s
INR:1.2 s
Fluid & Electrolytes
Diagnosis:
-None
History:
-Good fluid intake

+
+
+
+
+
+
+
+
+
+
+
+
+
+

+
+

-pt at risk for mobility difficulty,

stiffness, skin ulcers and
decrease in elasticity of
arteries, veins, joints and
muscles
-Pt is at risk for dehydration,
N/V/D and frequent headaches.
- Pt at risk for chest pain, blood
in urine as well as change in
hearing.
-pt at risk for dehydration,
swelling in legs and tarry
stools.

+
+
+
-

Lifestyle:
-Regular diet
-Incontinent

Assessments:
Amount of Fluid taken orally:

- Pt at risk for diminished

bowel function, loss of bladder
control, UTIs and rashes due
to urine and skin breakdown
-Pt is at risk for dehydration,

600 ml/day
Inspection:
-Urine x5/day: with foul odor
Palpation:
Skin turgor: Slow retraction
Edema: In legs
Lab Values:
Na: 137 mmol/L
Potassium: 4.1 mmol/L
Chloride: 99 mmol/L
Urea: 8.6 mmol/L
Creatinine: 87 mmol/L
Nutrition
Diagnosis:
-None
History:
- Poor appetite
Lifestyle:
-Regular food diet
Assessments:
W: 94 kg
Type of Diet: Regular
Appetite: Poor
Inspection: Symmetrical abdomen
Palpation: No hard areas or pain
Auscultation: Present bowel sounds
Medications:
- Pantaprozole
-

+
+
+
+
+

diminished skin turgor, skin

breakdown along with dry skin.
-Pt is at risk for frequent UTIs,
skin breakdown as well as
dehydration.
-Pt is at risk for dehydration
along with skin breakdown.
-Patient at risk of decrease in
circulation and fluid retention

-Patient is at risk for kidney

failure as well as kidney stones

-Patient at risk for malnutrition,

fatigue and weight loss

+
+
+
+
+
-Patient at risk for malnutrition,
fatigue and weight loss

Elimination
Diagnosis:
Incontinent
History:
N/A
Lifestyle:
-Low fluid/food intake
-Low activity level
Assessments:
Urinary output: 500ml/day

- Pt at risk for diminished

bowel function, loss of bladder

control, UTIs and rashes due
to urine and skin breakdown

+
+

-Pt at risk for dehydration

-Pt is at risk for weight gain,
muscle tone loss as well as
weight baring loss
-Pt at risk for fluid retention

Color: yellow
Odor: Yes,
foul
Infection: None
Bowel Habits: Irregular
Abdomen: Symetrical
BS x 4 quadrents: Present
Inspect: Skin dry, smooth no
tears
Palpate: No pain or hardening
Auscultate: Bowel sounds
present

+
+
+

Medications:
Docusate sodium
Lab Values:
Creatnine: 87 Umol/L
Urea: 8.6 mmol/L
Sodium: 137 mmol/L

Activity & Rest

Diagnosis:
stroke
History:
None
Lifestyle:
Rehab 1x/week, 10 at 10/daily
Occupational Therapy 3x/week
Assessments:
(Musculoskeletal Assessments)
-Poor weight baring
-Non-symmetrical strength
-Poor balance
Physiotherapy:
1x/week, 10 at 10/daily
Sleep:
Patient sleeps through the
night till morning
Skin Integrity
Diagnosis:
N/A
History:
N/A
Lifestyle:
immobile

-Pt at risk for infection

-Pt at risk for constipation,
bowel obstruction and fluid
retention

+
+
+

+
+
+

-Pt is at risk for recurrent

stroke, DVP, bedsores,
depression and decreased
swallowing ability.

+
+

+
+
+
+
+
+
+

-Pt at risk for falls and muscle

tone decrease
-Pt at risk for falls and muscle
done degeneration
-Pt at risk for falls and poor
muscle tone

Assessments:
Skin integrity: Good
Wounds: None
Dressings: None
Inspection/Appearance:
patients extremities are dry
Skin Turgor: Slow retraction
Medications:
- None
The Senses
Diagnosis:
Stroke, dementia
Lifestyle:
Mental state impaired
Assessments:
Vision: Good
Hearing: Good
Speech: Good
Tactile: Good
Olfactory: Impaired
Assistive devices: No
Pain: 0 on scale of 0-10
Medications:
Neurological Function
Diagnosis:
-Dimentia, stroke
History:
None
Assessments:
Mental Status: incompetent
Behavior: cooperative
Motor Function: operational
Strength in arms is not equal
bilaterally
Balance is inadequate for
ambulation
Tactile
Medications:
-Doneprezil
Endocrine Function/Reproduction
Diagnosis:
None

+
+
+
+
+
+
+

-Ptt at risk for skin break down

-Pt at risk for dehydration and
skin breakdown

-Pt is at risk for recurrent

stroke, DVP, bedsores,
depression, memory loss and
decreased swallowing ability.
-Mental impairment can put
patient at risk for confusion,
anxiety and falls

+
+
+
+
+

-Pt is at risk for recurrent

stroke, DVP, bedsores,
depression, memory loss and
decreased swallowing ability.
-Incompetency puts patient at
risk for confusion and anxiety,
which could result in falling if
confused.
-Pt at risk for falls
-Pt at risk for falls

+
+
+
+
+

-Pt at risk for hallucinations,

depression and loss of appetite

History:
None
Assessments:
Diabetes: N/A
BS: N/A
Lab Values:
TSH: 1.5 mIu/L
-creatnine: 87 Umol

Psychological Mode

+/-

Problem

Self-Concept
Personal self:
Coping mechanism:
Medication
Facial expression: Calm
Gender: Male
Age: 72
Interests to self: Eager to
recover and leave the hospital
as soon as possible.
Enjoys watching tv and
interacting with nurses who
are providing him care.
Role Function
-married, wife present in life
-Wife visits daily at the hospital to
deliver food to pt as well as bond
with him
-father of 3, kids present in life
-Home residence is a house
-Good self concept
Interdependence
Nursing care
two person assist with ADL

_
+
+
+

-Patient at risk for

dependency, addiction
and /or drug tolerance.

+
+

+
+
+
+
+
+
-

-Puts patient at risk for

falls with only one
caregiver