GROUP 4

NURSING CARE PLAN - 1

Patient: Doris Miller

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Risk for impaired After 1 hour of teaching Assess the overall skin The client's daughter is able to
skin integrity due to session, the client's condition of the client. verbalize 2 ways on how to
82- year-old the effects of daughter will be able to RATIONALE: To obtain prevent pressure ulcers after 1
Caucasian widow pressure of verbalize 2 ways on how baseline data of the hour of teaching session.
impaired physical to prevent pressure client's integumentary
Lives with her mobility secondary ulcers. status. The client's skin integrity
daughter, Delores to pain started to improve after 5 days
Ralston After 5 days, the client's Utilize a pressure ulcer as evidenced by decreased
skin integrity will start to risk assessment tool: redness in elbows and
“I don’t know how I improve as evidenced by ● Braden Scale sacrum.
ended up here. I decreased redness in ● Norton Scale
don’t know what I’d elbows and sacrum. RATIONALE: To The client gained 2 lbs. within
do without Delores, determine the degree of 1 week.
but if I could just Within 1 week, the the pressure ulcer
walk and didn’t hurt patient will gain at least 2 present so proper and The maceration of client's
so bad everything lbs. specific interventions antecubital spaces is
would be OK…I’ve could be carried out. prevented as evidenced by
always been able to Within 2 weeks, the dry and intact skin with no
take care of things. maceration of client's The client will be signs of maceration within 2
This just seems like antecubital spaces will be repositioned every 15 weeks.
such of a fuss over prevented as evidenced mins. in bed and every
nothing.” by dry and intact skin hour in chair.
without any signs of RATIONALE: To prevent
maceration. applying pressure on
Objective: bony prominences;
Has fallen pressure may lead to skin
numerous of times, breakdown due to
but this was the 1st impaired tissue perfusion.
time she broke any
bones with the fall Encourage use of pillows
or foam wedges to
Vital Signs: prevent bony
BP: 85/45 (right), prominences from direct
108/64 (left) contact with each other.
PR: 92 bpm Keep pillows under the
irregularly irregular heels to raise off bed.
RATIONALE: To reduce
Physical shearing forces on the
Examination: skin.
Height: 5’0”
Weight: 89 lbs. Encourage adequate
-Lung sounds are nutrition and hydration:
clear but only heard 2000-3000 kcal/day
in the upper lobes (more if increased
-Pale, thin, and dry metabolic demands), fluid
skin in most areas; intake of 2000 mL/day
appears intact and unless medically
well-cared for restricted
-Several large RATIONALE: To maintain
bruises on right skin turgor, moisture and
shoulder, upper suppleness which provide
arm, and hip resilience to damage
-Incision line 6” on caused by pressure.
right leg, slightly red
but no swelling or Clean, dry, and
drainage moisturize skin,
-Some redness particularly the bony
noted on elbows prominences BD or as
and sacrum, indicated by continence
antecubital spaces ot sweating. Avoid hot
are moist with some water. Use medical-grade
beginning cornstarch if powder is
maceration desirable; avoid talc
-Has 1+ pitting RATIONALE: To make
pedal edema skin become more
bilaterally smooth and supple so it
-Crepitus, grating, will be more resistant to
popping sound injury; these measures
bilaterally prevent evaporation away
-Increased from skin.
resistance and
rigidity when Wrap blisters with gauze
assisted with or apply a hydrocolloid
raising arms dressing.
-Noticeable RATIONALE: To prevent
contracted fingers harmful pathogens from
with swan-neck entering the skin.
deformities and
enlarged distal Teach the ptx. and her
interphalangeal daughter to massage only
joints around the affected area.
RATIONALE: To increase
According to tissue perfusion.
Delores:
-She can put just Educate patient and her
enough weight on daughter about the
her right leg to use causes of pressure
a walker ulcers.
-Needs assistance RATIONALE: To assist
when bathing, the patient and her
cooking, and daughter in finding
dressing methods to prevent skin
-Not eating very breakdown.
well, seems to
choke easily when Reinforce the importance
drinking of turning, mobility and
-Complains ambulation.
frequently of “dry RATIONALE: To enhance
mouth” their sense of efficacy
-Uses bed pads to and to improve their
manage small compliance with the
amount of prescribed interventions
incontinence during
the night Encourage ambulation if
the patient is able.
RATIONALE: To reduce
Past Medical Hx: pressure on skin from
Parkinson's disease immobility, thus, reducing
Osteoarthritis the factors that may result
Osteoporosis in impaired skin integrity.
Mitral valve disease
Communicate with a
Current dietician as appropriate.
Medications: RATIONALE: To aid the
Sinemet 25/250 mg ptx.and family in food
daily preferences to meet
Warfarin 5 mg daily, adequate nutritional and
MS Contin 15 hydration goals.
mg/12 hrs.,
Morphine sulfate 10 Educate ptx. and family
mg PO solution (10 about proper skin care.
mg/2.5 mL)/ 8 hrs. RATIONALE: To enhance
for breakthrough their sense of self-
pain efficacy and prevent skin
levothyroxine 0.05 breakdown.
mg every AM,
Miralax every other Communicate with a
day as needed for wound, ostomy and
constipation continence nurse
(WOCN).
RATIONALE: To assist
patient and family in
product selection,
 education, and
development of a
prevention plan.

NURSING CARE PLAN - 2

Patient: Doris Miller

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Impaired After 1 hour of Assess client's ability to The client and her daughter is
swallowing related teaching, the patient chew & swallow and observe able to verbalize at least 1
82- year-old to reduction in and the daughter will signs for difficulty in rationale for food consistency
Caucasian widow saliva as evidenced be able to verbalize at swallowing. and choices after 1 hour of
by choking, least 1 rationale for RATIONALE: Early teaching.
Lives with her especially when food consistency and assessment and detection
daughter, Delores drinking, and choices. reduces risk of aspiration. The client and her daughter is
Ralston complaints of able to verbalize at least 2
having a dry mouth. After 1 hour of Assess client's facial oral care techniques after an
“I don’t know how I teaching, the client muscles. hour of teaching.
ended up here. I and her daughter will RATIONALE: To detect if
don’t know what be able to verbalize at there are any abnormalities The client's complaint of
I’d do without least 2 oral care with the cranial nerves VII, having a dry mouth is already
Delores, but if I techniques. IX, X, and XII which control resolved after 5 days as
could just walk motor function in the mouth evidenced by moist mucous
and didn’t hurt so After 5 days, the and pharynx. membrane.
bad everything client's complaint of
would be OK…I’ve having a dry mouth will Provide adequate rest The client gained 2 lbs. after
always been able be resolved as periods for the client. 1 week.
to take care of evidenced by moist RATIONALE: Fatigue can
things. This just mucous membrane. further add to swallowing After 2 weeks, the client is
seems like such of impairment able to demonstrate effective
a fuss over After 1 week, the client swallowing after fluid intake.
nothing.” should gain at least 2 Eliminate any environmental
lbs. stimuli (e.g. TV, radio)
RATIONALE: To allow the
Objective: After 2 weeks, the ptx. to concentrate on their
client must be able to food intake and swallowing
Vital Signs: demonstrate effective
BP: 85/45 (right), swallowing after fluid Provide oral care before
108/64 (left) intake. feeding. Clean and insert
PR: 92 bpm dentures before each meal.
irregularly irregular RATIONALE: To promote
appetite and eating.
Physical
Examination: Consult a speech pathologist
Height: 5’0” for bedside evaluation
Weight: 89 lbs. evaluation ASAP.
-Lung sounds are RATIONALE: Early referral
clear but only leads to shortened recovery
heard in the upper time and decreased overall
lobes health costs
-Pale, thin, and
dry skin in most Use a dysphagia team:
areas; appears rehab. nurse, speech path.,
intact and well- dietitian, physician and
cared for radiologist who work
-Several large together.
bruises on right RATIONALE: To help the
shoulder, upper ptx. learn to swallow safely
arm, and hip and maintain a good
-Incision line 6” on nutritional status. Also for
right leg, slightly further assessment.
red but no swelling
or drainage Place suction equipment at
-Some redness the bedside and suction as
noted on elbows needed,
and sacrum, RATIONALE: To reduce risk
antecubital spaces of aspiration.
are moist with
some beginning Before feeding, provide the
maceration ptx. a lemon wedge, pickle,
-Has 1+ pitting or tart-flavoured hard candy.
pedal edema RATIONALE: To stimulate,
bilaterally lubricate food and improve
-Crepitus, grating, the ability to swallow.
popping sound
bilaterally Position ptx. upright (High
-Increased Fowler's position) and
resistance and maintain that position while
rigidity when feeding.
assisted with RATIONALE: To make
raising arms swallowing easier and
-Noticeable reduces risk of aspiration.
contracted fingers
with swan-neck Ensure ptx. is awake, alert,
deformities and and able to follow sequenced
enlarged distal directions before attempting
interphalangeal to feed.
joints RATIONALE: To reduce risk
of aspiration.
According to
Delores: Begin by feeding ptx. ⅓
-She can put just teaspoon of sauce. Provide
enough weight on sufficient time to masticate
her right leg to use and swallow.
a walker RATIONALE: Gravy/sauce
-Needs assistance added to dry foods facilitates
when bathing, swallowing.
cooking, and
dressing Classify food given to the
-Not eating very ptx. before feeding the ptx.
well, seems to RATIONALE: To allow the
choke easily when ptx. to prepare for
drinking appropriate chewing and
-Complains swallowing technique
frequently of “dry
mouth” Advance slowly, give small
-Uses bed pads to amounts; whenever possible,
manage small alternate servings of liquids
amount of and solids.
incontinence RATIONALE: To help
during the night prevent food from being left
in the mouth.

Past Medical Hx: Encourage high-calorie diet

Parkinson's that involves all food groups,
disease as appropriate. Avoid milk
Osteoarthritis and milk products.
Osteoporosis RATIONALE: Dairy products
Mitral valve can lead to thickened
disease secretions.

Current Administer pharmaceutical

Medications: agents as indicated - some
Sinemet 25/250 medications cannot be
mg daily crushed so the pharmacist
Warfarin 5 mg needs to be contacted;
daily, MS Contin medications can also be
15 mg/12 hrs., mixed in gelatin or custard;
Morphine sulfate or the medication may come
10 mg PO solution in elixir form.
(10 mg/2.5 mL)/ 8 RATIONALE: To reduce risk
hrs. for of aspiration
breakthrough pain
levothyroxine 0.05 Weigh patient weekly.
mg every AM, RATIONALE: To help
Miralax every evaluate nutritional status.
other day as
needed for Educate the patient and
constipation family about rationales for
food consistency and
choices.
RATIONALE: To avoid
disregarding necessary
dietary restrictions and giving
patient inappropriate foods
that may lead to aspiration.