NSG3MCC Assessment Task 3 Nursing Care Plan Template
Members in Group: Nicole Stafford 16445856, Baljit Pannu, Bonnie-Kate Wood 16133476, Denis Baniqued, Leah Dridan 16080544,
Melissa Salemme 15802975
Clients Gender: Female
Clients Age: 87
Medical Diagnosis: decreased mobility, UTI
Past Medical History:osteoartritis(severe), osteoporosis, proxysmol AF, vestibular dysfunction, PUD
Current Medications:
Clexane 20mg S/C daily 0800
Aspirin 100mg daily 0800
Alendronate 70mg weekly 0700
Sotalol 80mg BD 0800 & 2000
Sertraline 50mg daily 0800
Coloxyl & Senna 2 tablets BD 0800 & 2000
Paracetamol 1g QID 0800/1200/1800/2200
Assessment
Planning /Implementation
Evaluation
Nursing Diagnosis
Expected Outcome –patient goal
Nursing Interventions
Rationale
Outcome Assessment
Chronic pain related to
physical disability,
secondary to osteoporosis.
Patient will report decreased
levels of pain and increased
tolerance in performing
activities within one week.
Assess patient’s physical
symptoms of pain using a
pain assessment tool.
To assess the patient for
pain and to provide
successful pain
management
(Bruckenthal, 2008).
The patient verbalises reduced
pain assessment ratings.
Prior to the patient
performing an activity, carry
Pain limits mobility and is
often exacerbated by
Patient verbalises reduced
pain on mobilisation.
The patient may be
experiencing some
weakness due to a
decrease in bone density
secondary to osteoporosis.
The expected outcome will
be that the patient will be
more educated on how to
manage osteoporosis as well
as show an improvement in
their bone density and
out a pain assessment and
treat the pain accordingly.
movement (Ackley &
Ladwig, 2008)
Assess the patient’s
cognitive functioning using a
Mini Mental State
Examination.
To use appropriate pain
assessment tool and to
assess the extent of
which the patient will be
able to comply with the
pain treatment regime
(Scherder, Herr,
Pickering, Gibson,
Benedetti, &
Lautenbacher, 2009).
Patient suffers from
depression and occasionally
has short term memory
issues, medications are
prepared for her in a Webster
pack to improve medication
compliance.
Educate patient on
importance of taking
medications and the
relationship of the
medications with her disease
process.
To empower patients and
improve their knowledge
with regard to their
medications, which
optimises the likelihood
of patients to take their
medications (Nurit, Bar
Cohen, & Zelker Revital,
2009).
Verbalises importance of
medication and repeats back
understand of education
session.
Assess the patient’s bone
density by ordering a bone
density scan in order to
accurately assess the
deterioration of the bones.
Bone density scans are
usually used to analyse
the extent of the density
of the bones in order to
be able to plan out
treatment (Blake &
Continuous bone density
scans in order to determine an
improvement in bone density
and strength.
strength before being
discharged from the
hospital.
Fogelman, 2007). These
scans are also used to
measure any
improvement in bone
density once
interventions have been
put in place (Blake &
Fogelman, 2007).
Refer the patient to a
dietician who will organise
an appropriate diet for an
individual with osteoporosis.
A diet high in calcium will
help to prevent
osteoporosis as well as
slow down the
progression of the
disease in effected
individuals and therefore
increase their strength
(Stransky & Rysava,
2009).
Monitor the patient’s diet and
make sure that they are well
educated on the foods that
are beneficial to bone
strength.
Administer calcium and
vitamin D supplements.
Administering calcium
Make sure that the patient is
and vitamin D
taking their supplements.
supplements in the
treatment of
osteoporosis will help to
absorb the calcium in
their diet as well as
prevent the occurrence of
an osteoporotic fracture
(Stransky & Rysava,
2009).
Refer the patient to a
physiotherapist in order to
do simple strengthening
exercises.
Simple exercises such as
walking or simple
stretches can help to
strengthen bones as well
as prevent or slow down
progression of
osteoporosis (Keramat et.
al, 2008).
Allow the patient to
demonstrate various simple
exercises to promote bone
strength.
Educate the patient on
osteoporosis by providing
them with various brochures
and information sessions in
the community.
Education is important
for the patient to self
care for their
osteoporosis in the
community setting
(Nielsen et. al, 2010). It
may be beneficial for the
patient to join a
community group who
educate on osteoporosis,
as it has been proven to
be more successful in
slowing down the
progression of the
condition through
consolidating their
education into practice
and therefore producing
stronger bones (Nielsen
et. al, 2010). Group
sessions also increase the
likelihood that the patient
will adhere to their
Let the patient tell you about
osteoporosis and the
treatments to prevent further
progression and improve bone
density.
treatment plan (Nielsen
et. al, 2010).
Baljit diagnosis ???
Denis Diagnosis ???
Self-care deficit and
inability to perform
activities of daily living
related to disease
progression, weakness and
joint deformity.
Achieve independence of
self-care and maintain
optimal role function.
Monitor patient’s ability to
perform independent selfcare.
Knowing what the patient
is capable of enables us
to plan appropriate
interventions (Brown &
Edwards, 2008).
Monitor patient’s needs for
adaptive advices for personal
hygiene, dressing, grooming,
toileting and eating.
Advices can compensate
for contractures and
weakness, so that the
patient can perform as
many self-care activities
as possible, promoting
independence (Ward &
Loring, 2005).
Establish a routine for selfcare activities with rest
periods.
Establishing a routine
fosters maximum
independence for the
patient and rest periods
allow minimal fatigue
(Brown & Edwards,
2008).
Modifications to home such
as removing rugs, providing
rails and elevated toilet seat.
Modifications may be
necessary to allow the
patient to be as
independent as possible
without the risk of
possible injury (DVA,
2011)
Teach family to encourage
independence and to
intervene only when the
patient is unable to perform
the task
Teaching the family to
only intervene when
absolutely necessary is to
allow the patient to
understand they can do it
and gives them
independence in activites
(Ward & Loring, 2005).
Potential constipation
during hospital stay due to
decreased mobility and
analgesic medications.
Patient will maintain regular
to substantial bowel motions
during her hospital stay.
Observe and monitor usual
defecation patterns,
including amount, frequency
and stool consistency.
Compare this to regular
bowel motions of patient
prior to hospital stay and
during hospital stay.
This allows a baseline
that enables nursing and
medical staff to compare
if patient becomes
distended and impacted
(Gulanick & Myers, 2007).
Monitor the chart to recognise
any changes in bowel actions.
Encourage mobility and
ADL’s. Ensure these are
undertaken post pain
medication administration
for patient comfort.
Mobilising and being
active increases
peristalsis of the bowels
enabling bowel motions
and decreasing the
chances of constipation
(Gulanick & Myers, 2007).
The patient is more likely
to be apprehensive of
mobilising when there is
strong pain involved on
movement. Despite pain
medications contributing
to decreased elimination,
the patient is best to
mobilise out of bed when
medications are
administered, than nil
movement after
(Gulanick & Myers, 2007).
Reassess mobility levels daily
and determine which method
of mobilising is most
comfortable for the
patient.(Gulanick & Myers,
2007).
If patient is in too much pain
for weight bearing,
encourage movements on
the bed, including twisting
and changing positions while
in bed, lifting her left leg up
and down slowly, pulling her
left knee to her hip and
slowly straightening her leg.
Other exercises can include
lifting her upper torso
slightly whilst flexing her
abdominal muscles.
Encourage fluid intake, 6-8
glasses per day
Adequate fluid intake is
Use a fluid balance chart to
necessary to prevent hard monitor fluid intake and
and dry stools that are
difficult to pass (Eoff &
Lembo, 2008).
output.
Encourage oral intake, a diet
high in fibre.
When fibre reaches the
colon, it absorbs water
formin a gel and adding
bulk to faeces, enabling
full stools that are easy to
pass (Eoff & Lembo,
2008).
Use a food chart to monitor
nutritional intake.
Educate the patient on how
and why the constipations
have occurred, as well as
interventions they can
initiate to prevent it
Education will allow the
patient to understand
constipation better,
hence enabling them to
self initiate and manage
their own care (Eoff &
Lembo, 2008).
Assess the patients
understanding of constipation
and have them talk the steps
into preventing constipation.
Provide laxatives,
suppositories, and enemas
ordered or when required.
These soften stool,
lubricate intestinal
mucosa and help
peristalsis (Gulanick &
Myers, 2007).
Assess patients bowel chart
and ask patient about their
bowel motions, any
discomfort or pain that is
present. From this
information, determine if
medication will be needed.
(Eoff & Lembo, 2008).
Bibliography
Ackley, B. J., & Ladwig, G. B. (2008). Nursing diagnosis handbook: an evidenced-based guide to planning care. St Louis: Mosby Elsevier.
Blake, G.M., Fodelman, I. (2007). The role of DXA bone density scans in the diagnosis and treatment of osteoporosis. Postgraduate Medical Journal. 83(982),
509-517
Brown, D. (2008). Lewis’ Medical-Surgical Nursing: Problems related to movement and co-ordination (2nd ed) Chapter 28, 1812-1814. Elsevier Australia.
Bruckenthal, P. (2008). Assessment of Pain in the Elderly Adult. Clinics in Geriatric Medicine, 24(2), 213-236.
Department Of Veteran Affairs (DVA), 2011. Homecare and Support: Community Aged Care. Retrieved September 15th 2011 from www.dva.gov.au
Eoff J.C., & Lembo, A.J. (2008). Optimal treatment of chronic constipation in managed care: Review and roundtable discussion. Journal of managed care
pharmacy 14 (9), S5-S9.
Gulanick, M., & Myers, J. (2007). Nursing care plans: Nursing diagnosis and intervention. (6th ed.). St. Louis, Missouri: Mosby Elsevier.
Keramat, A., Patwardhan, B., Larijani, B., Chopra, A., Mithal, A., Chakravarty, D. (2008). The assessment of osteoporosis risk factors in Iranian women
compared with Indian women. BMC Musculoskeletal Disorders. 9(28)
Nielsen, D., Ryg, J., Nielsen, W., Knold, B., Nissen, N., Brixen, K. (2010). Patient education in groups increases knowledge of osteoporosis and adherence to
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Scherder, E., Herr, K., Pickering, G., Gibson, S., Benedetti, F., & Lautenbacher, S. (2009). Pain in dementia. Pain, 145(3), 276-278.
Stansky, M., Rysava, L. (2009). Nutrition as Prevention and Treatment of Osteoporosis. Physiological Research. 58(1), s7-s11
Ward. M, Loring. K (2005). Patient Education Interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with Non-Steroidal AntiInflammatory Treatment. 9 (4), 292-301