1 Nursing Care Plan: Assessment Database

Name: Cynthia Arce Date: February 11, 2019 Course: Clinical Nursing 220

Gordon’s Health Patterns

Subjective Data Objective Data Indirect
Health “I would rate my Vitals @7:42 am -An 85 year old
Perception/Health pain a 6 and I can -BP: 142/90 Caucasian female
Management tolerate it at about -Temp: 37.1 C, oral (Chart: Summary)
a 3.” -Pulse: 81 bpm -Full code status
“I’m cold can you -Respiration rate: (Admission sheet)
put my blankets 18 breaths per -She was brought in
over me.” minute because she had
“Honey I’m cold -Pain level: 6/10, confusion, and was
could you get my acceptable level lethargic. (Admission
sweater and put it was 5/10 sheet)
behind my head.” -SpO2: 92% -Braden Score: 14 (NPR)
“No numbness or -Room Air -Full code status
tingling.” -Side rails x2 (Admissions sheet)
“I’m alright, just -No visible distress- List of allergies:
tired.” -Sitting in semi Cephalosporins,
fowlers position Ciprofloxacin, Iodinated
-Left heal stage 2 Contrast Oral and IV
pressure ulcer Dye, Iodine,
Nitrofurantoin,
-A&O x3 Penicillins, Sulfa (Chart:
-Patient was alert Summary)
-incontinent -Admitted with altered
-Denies headaches mental status, she had
-Denies dizziness confusion, and was
-Denies numbers lethargic. She would
-Denies tingling wake up and closer her
-Altered ROM eyes right away. She is
-Muscle weakness also hard of hearing.
-Clear and coherent (Admission sheet)
speech -She was brought in by
-Altered skin her assisted living
integrity due to facility (Admission
bruising sheet)
-Hx of lung cancer, has
Vitals @14:56 a mass in her right
-BP: 137/84 lower lobe, received
-HR: 86 radiation treatments
-SpO2: 95, RA (Admission sheet)
-Temp: 36.9 C, oral -Dx of chronic disease:
-Resp: 18 Hypertension
-Pain: 5/10 (Admission sheet)
-Tolerance level: 3 -Dx of scoliosis
-Repositioned (Admission sheet)
2 Nursing Care Plan: Assessment Database

-Dx of PVD (peripheral

vascular disease)
(Admission sheet)
-On a dysphagia level 3
diet: soft foods and
small and thin liquids.
(Admissions sheet)

-Heparin Iv infusion
continuous 25,000 in
NaCl 0.45% 250 mL
PREMIX dose: 0-30
mL/hr (MAR)

Nutritional/Metabolic “I don’t like this -Ate 0% of her -Diet: Dysphagia level 3

food.” breakfast. diet, soft foods and
“This doesn’t look -Drank 180 ml small and thin liquids
very appetizing.” -Ate 0% of her (Admissions sheet)
“I’m not very lunch. -BUN: 22 mg/dL (Lab
hungry.” -Skin turgor: poor, sheet)
“I’ll just eat the it didn’t snap back -Creatinine: 1.61 mg/dL
yogurt.” fast (H) (Lab sheet)
“I just drank some -Skin was dry -Calcium: 6.8 mg/dL (L)
water and I’ll have -Bruising on arms (Lab sheet)
some apple juice.” -Bleeding from her -Chloride: 110 mEq/L
left arm. (Lab sheet)
-Bleeds easily. -Magnesium: 1.4 mg/dL
-Pressure ulcer (Lab sheet)
stage 2 on left heal: -Phosphorus: 1.5 mg/dL
changed dressing (Lab sheet)
because of -Ionized Calcium: 3.79 L
incontinence (Lab sheet)
-Pillow under her -Vancomycin: 1 g 200
right arm to ml/hr intravenous every
prevent pressure. 24 hours (MAR)
-Buccal mucosa and -Cardizem 30 mg tab
intact oral 4 times daily (MAR)
-cap refill </=3 -Pantoprazole 400 mg
-Hair is short, curly, oral daily (MAR)
and white -Metoprolol tartrate 50
-Nails are smooth mg oral 2 times daily
and healthy
-Skin: pale,
appropriate for
race, dry, no
lesions
3 Nursing Care Plan: Assessment Database

Elimination “I just went to the -Patient had 5 -BUN: 22 (H) (Lab sheet)
bathroom on bowel movements -Creatinine 1.61 (H)
myself.” while I was taking (Lab Sheet)
“I need to get care of her. -Metoprolol Tartrate 50
cleaned up.” -She was cleaned mg oral 2 times daily
“I need to get and changed every (MAR)
changed again.” time. -Vancomycin 1 g 200
“I feel like I used the -Urine: yellow in ml/hr intravenous every
bathroom on color 24 hours (MAR)
myself.” -Stool: green the -Pantoprazole 400 mg
“I’m going right first 2 times, then oral daily (MAR)
now.” brown the last 3
“I think I peed times, all were
myself.” large and soft.
Activity/Exercise “I can’t move on my -Right side scoliosis -Admitted with altered
own.” -Has a difficult time mental status,
“I need help to repositioning confusion, lethargy
move.” -Needs assistance (Admission sheet).
“I’m very weak.” x2 -Assistant living facility
“I don’t think I can -Could not tolerate brought her in because
hold onto the rails ADL’s except eating she was confused and
anymore.” on her own lethargic. (Admission
-Respiration sheet)
labored -Hx of lung cancer
-no wheezing (Summary)
-no cough -Pantoprazole 400 mg
daily tablets (MAR)
-Dx of Scoliosis
(Admission sheet)
-CT chest: found lung
mass, lower thoracic
scoliosis (Imaging)

Sexual/Reproductive “I have a son that -No lesions, -No Family he of any

works in inversions, or sexual/reproductive
construction, he leakage of breasts. health problems
recently just got a (Admission sheet/chart)
new job.” -Metoprolol tartrate 50
“My son comes and mg tablet oral 2 times
sees my on daily (MAR)
Saturdays.”
“I have a few
grandchildren, and
a new one on the
way.”
Sleep/Rest “I’m very tired but I -Rests when there -Metoprolol tartrate 50
can’t sleep because is no one in the mg tablet oral 2 times
people keep room daily (MAR)
4 Nursing Care Plan: Assessment Database
Cognitive/Perceptual
Role/Relationship
Self-Perception/Self-
Concept
bothering me and -Awakens easily -Cardizem 30 mg tablet
coming in my when I walked into oral 4 times daily (MAR)
room.” her room
-When she was in
deep sleep I had to
call her name and
she would wake up
-Calm
“ I don’t want a -Pt. Was A&O x3 -Admitted with altered
bath.” -hard of hearing mental status,
“I just have a little -Speech is clear and confusion, lethargy
pain.” coherent (Admission sheet).
“My arm is just -Alert when spoken -Assistant living facility
hurting now.” to brought her in because
“What did you say?” -Left arm 50% she was confused and
“They told me I power lethargic. (Admission
have to stay here -Patient sheet)
longer.” remembered that -Cardizem 30 mg tablet
“I don’t like being at her birthday was oral 4 times daily (MAR)
the hospital.” coming up soon.
“Yes my birthday is
coming up real soon
thank you.”
“I live in an assisted -Pt. Did not have -Widow (Summary)
living home where any visitors while I -Her emergency contact
they help me.” was there. was her son (Summary)
“My son comes and -She had on a few
visits me every rings that were
Saturday.” passed on to her
“I have a few from her mother
grandchildren, and and grandmother.
a new one on the
way.”
“These rings were
my mother and
grandmother’s and I
will give them to my
niece.”
“Come back to see -Needs assistance -Widow (Summary)
me okay.” with bath and -Cardizem 30 mg tablet
“I’m feeling perineal care oral 4 times daily (MAR)
depressed.” -Did not want to
“I don’t want to take a bath
take a bath right -Appears tired and
now.” weak
-Appeared to be
depressed
5 Nursing Care Plan: Assessment Database

Coping/Stress “I’m feeling -Confused upon -Hx of lung cancer

depressed.” admission but not (Summary)
“I just want to go anymore -Admitted with altered
home.” -can get agitated so mental status,
you have to help confusion, lethargy
her relax (Admission sheet).
-Likes to smile
when you help her
correctly and nicely
Values/Beliefs “My friend is -Was watching Joel -Non-denominational
converting me into Osteen on the (Admission Sheet)
Christianity.” television.
“It gives me hope
and peace.”
6 Nursing Care Plan: Assessment Database

DRUG/MED SHEETS
Drug Indication for Use Side Effects Nursing Patient
Responsibilities Assessment
Generic: Heparin General Use: Hemorrhage, easy -Assess for signs -Drug is
To stop and bleeding of bleeding and effective
Trade: Heparin prevent the Bruising hemorrhage. because it
Sodium formation of blood Thrombocytopenia -Monitor the prevented the
clots. Allergy or patient for patient from
Dose: iv infusion hypersensitivity hypersensitivity getting blood
continuous 0- Patient Use: reactions. clots.
3,000 units/hr Since the patient -Observe the -Patient was
0-30 mL/hr was bed bound she injection site for experiencing
-I should have was at a higher risk any skin changes easy bleeding
looked at the rate for thrombosis. such as and bruising,
she had infusing inflammation. the patient
per hour. also did not
have any blood
Classification: clots.
Anticoagulant -APTT: 100.7
(HH)
Generic: General Use: Hypotension -Assess the -The drug is
Vancomycin To treat potential Nausea patient for effective
life threatening Vomiting infection by -Patient’s
Trade: Vancocin infections, for Nephrotoxicity taking vital signs, temperature
patients who are Rashes checking the was in normal
Dose: 1 g in D5W allergic to penicillin, Back and neck pain appearance of limits
200 mL every 24 used to treat C-diff, Hypersensitivity wounds, sputum, -Temp @ 7:42
hrs intravenous and patients who reactions: chills, urine, and stool. am: 37.1 C
have fever, red man -Monitor the IV -Temp @ 14:56
Classification: staphylococcal syndrome closely for : 36.9 C
Tricyclic infections. Leukopenia irritation at the -Patient was
glycopeptide Eosinophilia site. experiencing
derivative, Anti- Patient Use: Ototoxicity -Monitor BP stomach
infective Patient is allergic to Phlebitis throughout Iv cramping but
penicillin so had to infusion. could have
use Vancomycin to -Monitor intake been cramping
prevent any and output ratios. to use the
infections from -Assess the bathroom.
bacteria. patient for -Patient said
superinfection. she was cold.
-IV site was
intact and no
redness.
7 Nursing Care Plan: Assessment Database

-BUN: 22
mg/dL (H)
-Creatinine:
1.61 mg/dL (H)
Generic: General Use: Used Depression -Assess the -The drug was
Prednisone to treat arthritis, Euphoria patient for any effective
blood disorders, Headache inflammation. because it
Trade: Deltasone breathing Personality changes -Monitor intake prevented the
problems, severe Restlessness and output ratios. patient from
Dose: 5 mg oral allergies, skin Cataracts -Assess the having any
daily administer diseases, cancer, Nausea/vomiting patient for any inflammation.
with food eye problems, and Decreased wound edema, rales, or - The patient
immune system healing crackles. denied the
Classification: disorders Hyperglycemia effects except
Corticosteroid Weight gain or loss being
Patient Use: Muscle wasting depressed.
Patient with history Osteoporosis -Intake: the
of lung cancer, Muscle pain patient did not
reduce swelling Hypokalemia eat anything
(patient was not -output: the
swelling but it was patient did
used as a have 5 bowel
preventative movements,
measure) in any and urinated
areas and any once on the
allergic reactions bed so it was
since the patient unable to be
was allergic to measured.
many different
medications.
Generic: General Use: treats Nausea -Assess the -The drug was
Pentoxifylline poor circulation by Vomiting patient for effective
improving the flow Gas intermittent because it did
Trade: Trental of blood through Bloating claudication keep blood
the vessels, it also Belching before and after flow in her
Dose: 400 mg decreases muscle Upset stomach giving the arms and legs,
tab(s) oral 2 times aching and pain Diarrhea medication. I assessed this
daily, swallow during exercise. Dizziness -Monitor the by checking
whole do not Headache patient’s intakes. capillary refill
crush Blurred vision -Monitor the on her toes
Patient Use: to Flushing patient’s blood and fingers,
Classification: treat PVD, to keep Chest pain pressure and she did not
Vasodilator blood flow in her Loss of appetite periodically. have edema,
Anti-inflammatory legs and arms since Rapid swelling or swelling in
she was bed bound her legs or
arms.
-The patient
had a loss of
8 Nursing Care Plan: Assessment Database

appetite and
0% of her
meals during
breakfast and
lunch.
-BP: @7:42
am: 142/90
-BP: @ 14:56:
137/84
-Patient denied
adverse effects
except upset
stomach which
may have been
the reason for
her many
bowel
movements.

Generic: General Use: -Headache -Monitor bowel -Drug is

Pantoprazole Treats -abdominal pain function effective
gastroesophageal -diarrhea -Monitor signs for because it did
Trade: reflux disease -eructation diarrhea, help her
Protonix (GERD) and a -flatulence abdominal swallowing
damaged -hyperglycemia cramping, fever, -Patient denied
Dose: 40 mg dose esophagus. It also -bone fracture and bloody stools side effects
400 mg daily at 6 treats high levels of -hypomagnesemia -Monitor lab -WNL stool
AM, swallow stomach acid values for -Stool was
whole do not caused by tumors. hypomagnesemia brown, liquidy,
chew or crush periodically. green at times,
Patient Use: to for her 5 bowel
Classification: treat difficulty movements
Anti-ulcer agent, swallowing since she had
proton pump she had dysphagia throughout the
inhibitors level 3. day.
-Urine and
stool
incontinence
-Urinated one
time, a large
amount (onto
the bed so
couldn’t record
it exactly).
-Temp 36.9 C
-Magnesium:
1.4 mg/dL (L)
9 Nursing Care Plan: Assessment Database

Generic: General Use: It is Hypertension -Assess the -The drug was

Metoprolol used to treat Angina patient’s blood effective
Tartrate (short hypertension, Tiredness pressure because it
acting) treatment of Dizziness throughout the lowered the
angina, treatment Depression day to see if it patient’s blood
Trade: Lopressor of Wheezing lowered. pressure.
hemodynamically (bronchospasm) -Monitor the -BP @7:42 am:
Dose: 50 mg stable patients, Diarrhea patient’s heart 142/90
tab(s) oral 2 times decreases heart Nausea rate frequently. -BP @14:56:
daily rate Dry mouth -Monitor output 137/84
Gastric pain and intake ratios -HR @7:42 am:
Classification: Constipation -Assess for HF 81 bpm
Selective beta 1 Flatulence and any signs of -HR @14:56:
adrenoreceptor Pruritis angina 86 bpm
blocker, Patient Use: to Rash -Monitor lab -Patient had no
antihypertensive, lower the patient’s Mental status values such as an abnormal
antianginal, blood pressure changes increased BUN heart sounds.
adrenergic since she had high -Intakes: The
antagonist blood pressure. patient didn’t
eat anything.
-Output: The
patient had 5
bowel
movements,
and urinated
once but was
unable to be
measured.

-Patient denied
dizziness
-Patient was
not confused
-BUN: 22
mg/dL (H)
-I should have
assessed chest
pain (although
she said she
didn’t have any
pain).
-I should have
also assessed
for more signs
of HF which
include
shortness of
breath, lack of
10 Nursing Care Plan: Assessment Database

energy (which
she had),
swelling of legs
and feet
(which she
didn’t have).

Generic: General Use: Bleeding -Assess for signs -Drug is

Enoxaparin Used for Hemorrhaging of bleeding and effective, the
prevention of Thrombocytopenia hemorrhaging patient did not
Trade: Lovenox venous Local reactions such -Assess for local get any blood
thromboembolism as irritation, pain, reactions at the clots
Dose: 1mg/kg and/or pulmonary hematoma, injection site -The patient
dose 50 mg embolism in ecchymosis, -Let the patient did not have
subcutaneous patients, treatment erythema know that it may any rashes,
every 24 hours of DVT, and Fever take them longer skin was intact
prevention of Edema to stop bleeding and dry, and
Classification: ischemic Nausea and that they appropriate for
Antithrombotic complications. It is Diarrhea may bruise and her ethnicity.
Anticoagulant also used for Dizziness bleed more -Areas
Low molecular outpatient Constipation easily. bleeding on
weight heparin treatment. Vomiting -Assess for black, right arm.
Urinary retention tarry stools -APTT: 100.7
Patient Use: The Anemia -Monitor the sec. (HH)
patient was Headache patient for -Denies
receiving Heparin, Insomnia hypersensitivity dizziness
and it was replaced reactions -Temp: 36.9 C
with Lovenox - Patient had 5
because it lasts bowel
longer than movements
Heparin, and it is -Urine: yellow
injected under the in color
skin instead -Stool: green
through IV. They the first 2
switched to times, then
Lovenox because brown the last
she was getting 3 times, all
ready to go home were large and
and they wanted soft.
her body to get - I should have
used to it since she assessed the
was being sent patient’s
home with it. understanding
of education
that they will
bruise and
bleed more
easily, and how
11 Nursing Care Plan: Assessment Database

they will
receive it at
home.
Generic: Diltiazem General Use: -abnormal dreams -Assess the -The drug was
Vasodilation -anxiety patient for any effective
Trade: Cardizem resulting in -confusion rash because it did
decreased BP, -dizziness -Monitor intake decrease the
Dose: 30 mg oral treats angina. -drowsiness and output ratios patient’s blood
4 times daily -headache -Assess for signs pressure.
Patient Use: to -nervousness of HF -BP @7:42 am:
Classification: decrease blood -weakness -Monitor BP and 142/90
Antianginal, pressure since she -cough HR before giving -HR: 81 beats
Antirrhythimics, had high blood -blurred vision the medication, per minute
Antihypertensives, pressure. -dermatitis after giving the -BP @14:56:
Calcium channel -nausea medication, and 137/84
blocker -vomiting periodically after. -HR: 86 beats
-bradycardia -Assess the per minute
-chest pain patient for angina -Patient denies
-tachycardia -Consider lab dizziness
-constipation values such as -Patient denies
-anorexia calcium levels effects except
-polyuria -The patient’s drowsiness
renal function and weakness.
should be -Ionized
checked Calcium: 3.79
periodically mg/mL (L)
-Calcium: 6.8
mg/mL (L)
-The patient
had impaired
renal function
but it was
improving.
-BUN: 22
mg/dL (H)
-Creatinine:
1.61 mg/dL (H)
-No rash
present
-HR @14:56:
86 bpm
-Pt on
telemetry
-Temp: 36.9 C
-Respirations:
18 breaths per
minute
12 Nursing Care Plan: Assessment Database

Resource:
DavisPlus - student and instructor online resource center supporting F.A. Davis titles. (2018,

August 15).

LAB VALUES
Test Normal Value Patient Value Interpretation
Ionized Calcium 4.43-4.93 mg/dL 3.79 mg/dl Ionized Calcium is calcium in your blood that
is not attached to proteins. The patient’s
Ionized Calcium value is low. This patient
could have received this test since she had
lung cancer in the past, and also since
calcium is needed for prevention of blood
clotting (AACC, 2018).

APTT 23.0-32.4 sec 100.7 sec Since this patient was on Heparin, she
needed this test. The patient’s activated
partial thromboplastin time is very high. The
time in seconds that it takes for clotting to
occur when reagents are added to plasma in
this patient is 100.7 seconds. (AACC, 2018).

Phosphorus 2.5-4.9 mg/dL 1.5 mg/dL This patient had a low level of phosphorus in
her blood because she was malnourished
since she was not eating well and was very
weak (AACC, 2018).
Magnesium 1.6-2.6 mg/dL 1.4 mg/dL The patient had a low level of magnesium
because she may have not been consuming
enough since she was malnourished which is
commonly seen in the elderly. (AACC, 2018).
13 Nursing Care Plan: Assessment Database

MCHC 31.6-34.8 % 31.5 % Decreased levels of the mean corpuscular

hemoglobin concentration is the average
concentration of hemoglobin in your RBC’s.
This patient could have had a low level
because she had cancer or not enough
hemoglobin. The patient was not anemic so
that was not the reason. (AACC, 2018).

Chloride 98-107 mEq/L 110 mEq/L The patient could have had an increased level
of chloride because she could have been
dehydrated or because she had impaired
renal function. (AACC, 2018).

Creatinine 0.51-0.95 mg/dL 1.61 mg/dL An increased level of Creatinine was most
likely from her impaired renal function and
hypertension. (AACC, 2018).

Calcium 8.5-10.1 mg/dL 1.61 mg/dL Low calcium levels were seen because she
was malnourished since she was not eating
well. The patient could have also had low
calcium because the patient had decreased
renal function which eventually started
improving. (AACC, 2018).

BUN 7-18 mg/dL 22 mg/dL This is to test Blood Urea Nitrogen, and the
patient had a high level. This patient could
have gotten this test to evaluate the health of
her kidneys. Since she had a high level that
means that she had impaired kidney function,
which she did have. (AACC, 2018).
14 Nursing Care Plan: Assessment Database

NURSING DIAGNOSES
Diagnosis: 1: Disturbed body image r/t altered body structure

Supporting data: Scoliosis, depression, skin breakdown, confusion.

STG: Patient incorporates changes into self-concept without negating self-esteem by the end of the day.

Plan for the day: Talk to the patient about her feelings, therapeutic communication, therapy.

Diagnosis: 2: Risk for falls r/t confusion

Supporting Data: confusion, malnutrition, lethargy, skin breakdown, bed bound, hearing difficulty,
scoliosis, weakness.

STG: The patient will not have any falls the whole day.

Plan for the day: Bed rails x2, bed alarm on and working, pillows on her sides so she doesn’t roll over,
bed low and locked, check not the patient frequently.

Diagnosis: 3: Risk for infection r/t impaired skin integrity

Supporting data: several IV sites, incontinence, pressure ulcer stage 2 on heel left foot, bleeding in
multiple places on her body (Heparin), UTI.

STG: The patient will verbalize which symptoms of infection to look out for by the end of the day.

Plan for the day: Change dressing frequently or as needed, reposition the patient so the wound doesn’t
get worse, waffle boots.
15 Nursing Care Plan: Assessment Database

Student Name: Cynthia Arce Date of Clinical Encounter: February 11, 2019

Patient Initials: JB Age: 85 Gender: Female Admission Date: February 7, 2019

Primary Medical Diagnosis: UTI (Urinary Tract Infection)

A urinary tract infection is an infection caused by organisms that are pathogenic like fungi or bacteria in
any place in the urinary tract. UTI’s are common in the United States. There is an estimated amount of
seven to 10 million people a year who visit the doctor with a UTI. Some risk factors for getting a UTI are
any interruption of the flow of urine, kidney stones, enlarged prostate, or any urethral abnormalities in
the urinary tract (Al-Badr, 2013). There are many people who don’t notice that they have a UTI. UTI’s
can cause pain, a burning feeling when urinating, organ damage and even death. This infection is very
important because the kidneys are the organs that produces the urine. The kidneys keep everything
balanced and removes the waste products. If the kidneys are damage, they will not be able to take out
the wastes. Women are more susceptible to getting an UTI than men the urethra is shorter in women
and the exit is close to the vagina and the anus which can lead to pathogens getting in easier. People
who have catheters have a great risk of getting a UTI since catheters don’t have a protective barrier.
Some common symptoms of a UTI are cloudy urine, dark or bloody urine, pain, fever, chills, strong smell
of urine, burning sensation, the urge to urinate frequently, discharge, and back pain. To treat a UTI,
people are sometimes given antibiotics through an IV, or oral antibiotics. The most preventative ways to
prevent UTI’s, are to drink plenty of liquids such as water, and wipe front to back. (Davis, 2015).

Secondary Medical Diagnosis: Peripheral Vascular Disease (PVD)

Peripheral Vascular Disease (PVD) is a disease of the arteries and veins that are located outside of the
brain and heart. Some symptoms of PVD are hair loss over the top of the feet, weakness and atrophy of
the calf muscle, feet may turn pale when they are elevated, and poor wound healing, numbness,
coldness, and color changes in the legs or feet. Rest pain is most common. It happens when a person is
laying down and faced up. It typically occurs at the feet and happens because there is not enough
oxygen and blood supply to the legs. Arm or leg pain, and cramping also happens. PVD is seen more in
men than women. It is seen more in the elderly and people over the age of 50. The risk factors are high
levels of LDL cholesterol, low levels of HDL cholesterol, diabetes, family history of PVD, obesity, renal
failure, cigarette smoking, and physical inactivity. The treatment is smoking cessation and having a
healthy diet. Exercise should be improved and medications such as anti-platelet medications,
anticoagulant medications, cholesterol lowering drugs and drugs to control hypertension could be
options to take. The most preventative measures to prevent PVD are to stop smoking, maintain a
healthy weight, and control high blood pressure (Stöppler, 2018).

Related Surgical History:

There was no surgical history in the patients’ record.
16 Nursing Care Plan: Assessment Database

NANDA NOC NIC

Nursing Diagnosis: NOC: Body image NIC: Spiritual Support (Johnson, 2014, pg. 48).
Disturbed body (Johnson, 2014, pg. 48)
image (Doenges,
2019, pg. 69).

Definition: Definition: Perception of Definition Spiritual support helps you find value,
Confusion [and/or own appearance and body meaning, trust, and strength during difficult
dissatisfaction] in functions times (Johnson, 2014, pg. 48).
mental picture of (Johnson, 2014, pg. 48).
one’s physical self
(Doenges, 2019, pg.
69). Activity 1: Perform a comprehensive assessment
Indicator: Self Awareness of spiritual health to make patient centered
(Johnson, 2014, pg. 49). clinical decisions (Potter, 2017, pg. 737).

1 Intervention:
Nursing Diagnosis STG: The patient will state Convey caring and openness to successfully
Statement: or demonstrate promote honest discussion about the patient’s
Disturbed body acceptance of change of spiritual beliefs.
image r/t altered loss of body function by
body structure the end of the end of the Rationale:
week. Assessing a patient’s spiritual health is essential
to take the time to listen to your patient’s
viewpoints and establishing a trusting
AEB: relationship (Potter, 2017, pg. 737).
-Scoliosis LTG: The patient will
-Negative feelings acknowledge the self as an
about body individual who has Evaluation:
-Patient verbalized responsibility for self by The patient’s spiritual health was assessed. The
feelings of the end of the month. patient felt good to talk about her faith and how
depression by she believes in God.
stating “I’m
depressed.” Activity 2:
-Skin breakdown Indicator: Self esteem Have the patient talk about her faith, hope, and
-Confusion enhancement (Johnson, assess the source of authority and guidance that
-Patient felt 2014, pg. 49). the patient uses in life to choose and act on their
powerless by stating beliefs (Potter, 2017, pg. 738).
“I don’t have the
strength to move on STG: 2: Intervention:
my own.” Patient incorporates Discuss what’s meaningful and relevant to the
-not socially active changes into self-concept patient and listen to what the patient has to say.
because the patient without negating self-
feels as if she is esteem by the end of the Rationale:
powerless because day. Listening provides support or comfort in spiritual
she has scoliosis. care. Caregivers engage in “meaning making’
activities by expressing important values such as
17 Nursing Care Plan: Assessment Database

hope, dignity, and togetherness (Potter, 2017,

LTG: pg. 737).
The patient will return to
previous social Evaluation:
involvement by the end of The patient expresses her feelings about what
the month. she believes in and expressed a personal sense
of spiritual well being. She explained that God
gave her hope and that he’s what keeps her
calm through her illnesses.

Activity 3:
Provide the patient with your presence, because
nurses contribute to a sense of well-being and
provide hope for recovery when they spend time
with their patients (Potter, 2017, pg. 744).

3 Intervention:
Plan discussions with the patient during
treatment and listen, allowing her to sort out
concerns she might have about her future.

Rationale:
Presence is a part of nursing. Presence involves
“being with” a patient versus “doing for” a
patient. It is being able to offer closeness with a
patient physically, psychologically, and
spiritually. It helps to prevent emotional and
environmental isolation (Potter, 2017, pg. 744).

Evaluation:
The patient let out her feelings as I sat next to
her to listen to what she had to say. She needed
that closeness from someone since her son
could only visit her on Saturdays. Therefore, me
being with her and close to her to talk about her
feelings, allowed me to become close to her and
offer her emotional support.

Activity 4:
Determine who provides the greatest source of
strength and support to patient during times of
difficulty (Potter, 2017, pg. 740).

4 Intervention:
18 Nursing Care Plan: Assessment Database

Have the patient review her discussions with her

family and friends that will help her with her
spiritual health.

Rationale:
Significant others such as spouses, siblings,
parents, and friends need to be involved in the
patient’s care as appropriate. These individuals
sometimes become involved in all levels of the
plan of care. They often assist in giving physical
care, providing emotional comfort, and sharing
spiritual support (Potter, 2017, pg. 743).
Evaluation:
The patient is connecting with family and church
members. She is able to express a sense of hope.
She stated “believing in God really makes things
easier, and makes me feel good about myself.”
She also talked about how her friends are
helping her believe in God more.

NOC Evaluation: The patient was able to improve her self esteem issues. The short term goals were
met but the long term goals were not since I was not able to assess her for the whole month. During
my final visit with the patient, she thanked me for trying to help her understand her diagnosis and
making her feel happier with herself. She continued to have faith in God and this is making her self
acceptance and social activity increase. Encourage the patient to believe in herself and compliment
her on how she is doing to give her hope. Continue daily self esteem and spiritual support assessment
by asking her how she feels about herself and monitor her depression frequently. Let the patient
know that you are there for her whenever she needs to talk so she doesn’t get lonely.
19 Nursing Care Plan: Assessment Database

REFERENCES
AACC. (2018, December 19). Ionized Calcium.

Al-Badr, A., & Al-Shaikh, G. (2013). Recurrent Urinary Tract Infections Management in

Women : A Review Sultan Qaboos University Medical Journal,13(3), 359-367.

doi:10.12816/0003256

Center for Drug Evaluation and Research. (2018, February 6). Drug Safety and Availability -

Generic Enoxaparin Questions and Answers.

Davis, C. P., (2015, August 19). Urinary Tract Infection (UTI): Symptoms and Treatments.

DavisPlus - student and instructor online resource center supporting F.A. Davis titles. (2018,

August 15).

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing diagnosis manual: Planning,

individualizing, and documenting client care(5th ed.). Philadelphia: F.A. Davis

Company.

Drugs & Diseases. (2019).

FDA. (2018, February). Drug Information, Side Effects, Uses.

20 Nursing Care Plan: Assessment Database

Johnson, M. (2012). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting

critical thinking and quality care(3rd ed.). Maryland Heights, MO: Elvesier Mosby.

Mayo Clinic. (2019, February 01). Prednisone (Oral Route) Description and Brand Names.

Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2017). Fundamentals of nursing(9th ed.).

St. Louis, MO: Mosby Elsevier.

Stöppler, M. C. (2018, January 19). 9 Peripheral Vascular Disease Symptoms, Signs, Treatment

& Risks.