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Nursing Care Plan

Meggan Nanton
NorQuest College
NPRT 2102
Acute Care Clinical Practicum
Instructor: Rhonda Meredith
June 03, 2014

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Nursing Assessment Tool: A Systems Approach

SYSTEM

ASSESSMENT

FINDINGS

Respiratory System

Respiratory rate and rhythm

Cardiovascular
System

History

Nervous System

Level of consciousness Glasgow

Blood pressure & Pulse

Client has a history of M.I.

Recent blood pressure and
Pulse were within normal
limits according to the chart.

Client oriented to person,

place and time.

Client has not taken anything

for pain in the previous
24hours.

Client is susceptible to pain

however due to perineal
cellulitis, a wound packed
dressing on his back and a
recent wound vacuum
procedure done yesterday to
his scrotum.

Food intake

History

Height

Weight

Client is on a diabetic/Heart
Healthy Diet and yesterday
was NPO.
Client has high cholesterol
Client is 175 cm
91kg
Clients BMI is
29.71(preobese)
Will need to assess client for
regular bowel sounds and for
pain.
Clients C.B.C.s, Bun and
Creatine lab val;ues are to be
monitored.

Coma Scale
Evidence of pain acute or chronic

Description of pain experience

location, source, onset, duration

Gastrointestinal
System

Recent respiratory rate was

within normal limits
according to the chart.

Body Mass Index(BMI)

Bowel sounds

Pain

Fluid intake & output 24 hours

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SYSTEM
Urinary System

ASSESSMENT
Urine amount, colour, transparency,

odour

Musculoskeletal
System

Integumentary
System

Client has a Foley

Clients urine yesterday was
clear and Foley was draining
adequately according to the
chart

Posture, gait, coordination

Client had a fall on May 17th,

2014, due to mismanaged
blood sugars.

Evidence of injury/trauma

Client fell on scrotum which

led to scrotal damage.

Condition of skin, scalp, nails, mucous

Skin around scrotum and back

will need to be assessed and
wound care done as required.

The clients temperature

yesterday was within normal
limits according to the chart.

membranes

Body temperature

Endocrine System

FINDINGS

Structural change in skeleton, adipose

Monitor scrotum, and back

for changes in the wound
tissue.

Endocrine sytem

Check blood sugars four

times a day.

Pathological History

Client is classified as aNonInsulin Dependent diabetic.

Clients C.B.C.s, Bun and

Creatine lab val;ues are to
be monitored.

tissue, integument
Functional change in:

Lab test findings

Senses

Degree of function and effects of

altered sensation in each of the senses:

vision, hearing, touch, smell, taste

Client wears glasses and

upper dentures.

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SYSTEM
Environmental
Factors that Affect
Function of Systems

ASSESSMENT
Support systems

Lifestyle factors

Medical diagnoses

Medications

Determinants of health

FINDINGS
The patient lives with brother
and son, who have been
working with the social
worker on decisions regarding
his care.
Clientss last job ended in
February and he currently
does not have health benefits.

He has Non-Insulin
Dependent Diabetes, has
previously had a heart attack
and has high cholesterol.

Patient takes Acetylsalicylic

Acid, Atorvastatin, Calcium
Carbonate, Centrum Forte,
Heparin Sodium, ImipenemCilastatin Sodium MB-Plus,
Metformin, Metoprolol,
Nystatin, Ramipril, Toronto,
Human Insulin and Vitamin
D. His P.R.N medications
include Dilaudid, Gravol,
Tylenol, Tylenol # 3 and
Zofran.

The Client is affected by the

Income and Social
Status,determinant of health
as outlined in Potter and Perry
(2010, p.6,7). He fell because
he was not managing his
diabetes accordingly because
he could not afford the
medication according to the
chart.

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Nursing Care Plan

Nursing Diagnosis

Planning

Interventions

Evaluation

Actual Problem:
Impaired Tissue
Integrity of the
Scrotum and the Back
related to the patients
poor diabetic
management as
evidenced by his falls.

Goal: To prevent further

skin breakdown on the
patients Scrotum and Back.

1 The student practical nurse will

consult with the head nurse and the
dietician to assess what methods would
work best to prevent these wounds from
becoming exacerbated.

S: Patient will participate in

a wound survey.

2-Student will cleanse and provide

tissue care as needed.

1. Achievement of Expected
Outcomes: The goal was met as
the patients wounds on both his
scrotum and back did now
worsen as evidenced by the
unchanging measurements.

M: Patient will then list 3-4

things,

3-Discourage the patient from

scratching or touching his wounds.

A: that he himself can do to

prevent the deterioration of
the wound.

Rationale for Interventions

R: He can do so in
collaboration with the ideas
of the Dr., nurses,
Pharmacist and Dietician.

1. Taking an interdisciplinary approach

with patients gives the client the best
outcome when caring for a wound
(Potter & Perry, 262).

T: This goal will commence

June 3rd to June 6th, 2014.

2. First of all cleansing is important to

remove harmful microorganisms and
debris and secondly tissue care is vital

2. Patient Responses and

Findings: The patient also stated
that by doing a wound
questionnaire it enabled him to
proactively care for his wounds
and helped to prevent the further
progression of the wounds.
3. Further Nursing Actions: The
Outcome was met as indicated
by both wounds lengths and
widths (they remained the
same)|.

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because the dressing replaces the

protective function of the injured tissue
during the healing process(Gulanick &
Myers, 2014 p.196).
3.The above actions according to
Gulanick and Myers can worsen the
wound and slow down the healing
process(2014, p.196).

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Potential Problem:
Risk for Falls related to
the patients unstable
blood sugars as
evidenced by his fall on
May 17th, 2014.

Goal: To prevent client from 1. The student nurse will assess the
experiencing more falls.
client for signs of confusion.
S: The patient will wear
well fitted shoes when
walking, wear pajamas and
robes that do not drape on
the ground and will avoid
wet and uneven surfaces.
MA: The client will display
these behaviours everyday
R: during the practical
student nurses shift from
7:00-2:00.
T: This goal will be
maintained from June 3rdJune 20th, 2014.

2. The student will answer the patients

call bell as soon as possible.
3. Encourage the patient to have their
bed in the lowest position possible and
to ring for help if they need assistance
getting out of bed.

Rationale
1. A confused state of mind is often
linked to dizziness, loss of ones sense
of position and ultimately loss of
balance (Day, Paul, Williams, Smeltzer,
and Bare, 2010, p. 234).
2. Patients who have to wait an
extended period of time may do unsafe
activities on their own if they have to
wait too long (Gulanick & Myers, 2014,
p.65).
3. According to Potter and Perry, falls in
older adults are often caused by getting
out of bed too quickly and without
assistance (2010, p. 396).

1. Achievement of Expected
Outcomes: The Goal was
achieved primarily because the
patient strived to wear the right
attire while in the hospital and
was more careful noting what
surface he was walking on.
2. Patient Responses and
Findings: This goal was also
successful because the patient
was motivated to learn.
3. Further Nursing Actions: Are
not needed because the patient
goal was met and patient vows
to be more careful and take all of
his medications in the future
(social assistance for this
pending).

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Educational:
Knowledge deficit:
Ineffective Health
maintenance as
evidenced by patients
smoking status.

S-Patient will be able to

discuss the side effects of
smoking with the student
nurse.
M-The Patient will describe
two ways in which smoking
affects their diabetic
condition and how their
heart works.
A-Patient is alert and aware
and cognitively capable of
verbalizing the side effects
of smoking.
R-This goal is attainable as
the patient can be given
educational aides o research
this topic.
T-This discussion will take
place between June 3rd and
June 6th, 2014.

1 I: The student practical nurse will

discuss the benefits of quitting smoking
with the client.
2. I: Talk about smoking cessation aides
with the patient such as the patch, gum
and prescriptions like Wellbutrin.
3.-I: Discuss with the patient coping
methods to not smoke too alleviate
stress or anxiety.

Rationale
1. Quitting smoking cuts the risk of
Coronary Heart disease by 50% and
following 2 weeks-3 months of quitting
smoking, ones circulation is
improved(Gulanick and Myers, p. 227)
2. Smoking cessation is twice as
affective when nicotine replacement
methods are used as opposed to a
placebo (Gullanick and Meyers, p.227).
3. Smoking according to Gullanick and
Meyers is often used to combat stress,

1. Achievement of Expected
Outcomes: The goal was
achieved as the patient willingly
participated in all discussions.
2. Patient Responses and
findings: The interventions were
especially helpful to the client as
teh client did not realize how
much more successful people
were, when they incorporated
nicotine replacement therapy
into quitting smoking.
3. Further Nursing Actions: The
client now understands why it is
important to quit and
consequently the next nursing
action would be encouraging the
client to quit.

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however alternative methods exist that

can be prescribed such as deep
breathing, exercising and joining local
support groups (2014, p.228).

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Summary
A nursing diagnosis according to Durand & Prince is the nurses perspective on the
appropriate focus for the client (Potter & Perry, 2010, p. 64), and is the first step in the nursing
process. This integral part of nursing care helps the nurse determine what problems are present
and furthermore what nursing interventions will work to solve these problems (providing
decisions are evidenced based). In this case, evidence based interventions and outcomes helped
me to decide that the patient needed help with his wound care (an actual problem), and guidance
to prevent him from falling again (a potential nursing diagnosis). The nursing process
furthermore prompted me to form an educational goal, and through this structured way of
thinking I knew I needed to teach my patient more concerning the ill effects of smoking and to
evaluate whether my teachings were effective or not .

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References:

Day, A.R., Paul, P., Williams, B. Smeltzer, S.C., Bare, B. (2010). Brunner & Suddarth's textbook
of Canadian medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
Gulanick, M., Myers, J.L., (2014). Nursing Care Plans: Diagnoses, Interventions and
Outcomes(8th ed.).Philadelphia, PA: Elselvier
Potter, P.A., & Perry, A.G. (2010). Canadian fundamentals of nursing (4th ed.). Ross-Kerr, J.C.,
& Wood, M.J. (Eds., Cdn. ed.). Toronto, ON: Elsevier.