NSG3MCC Assessment Task 3 – Nursing Care Plan
Group:
Purple Group 1.
Group Members:
Nicole Stafford, 16445856
Baljit Pannu,
Bonnie-Kate Wood, 16133476
Leah Dridan, 16080544
Melissa Salemme, 15802975
Denis Victor Baniqued, nil submission
Cassian Lawrence, claims in another group nil submission
Group Facilitator:
Anne Booms
1
Index
Introduction ..............................................................................................
4
Diagnosis 1 - Chronic pain related to physical disability, secondary to
osteoporosis. By Nicole Stafford 16445856 ..............................................
5
Diagnosis 2 - The patient may be experiencing some weakness due to a
decrease in bone density secondary to osteoporosis.
By Melissa Salemme 15802975 ..................................................................
6
Diagnosis 3 - Self-care deficit related to limited mobility due to severe OA.
By Baljit Pannu
..........................................................................
8
Diagnosis 4 - Self-care deficit and inability to perform activities of daily
living related to disease progression, weakness and joint deformity.
By Bonnie-Kate Woods 16133476..............................................................
10
Diagnosis 5 - Potential constipation during hospital stay due to
Decreased Mobility and analgesic medications.
By Leah Dridan 16080544 .........................................................................
11
2
Conclusion - By Nicole Stafford 16445856 ..............................................
14
Bibliography
15
...........................................................................................
3
NSG3MCC Assessment Task 3 Nursing Care Plan.
Members in Group: Nicole Stafford 16445856, Baljit Pannu , Bonnie-Kate Wood 16133476, Leah Dridan 16080544,
Melissa Salemme 15802975.
Clients Gender: Female
Clients Age: 87
Medical Diagnosis: decreased mobility, UTI
Past Medical History: osteoarthritis (severe), osteoporosis, paroxysmal 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
In this care plan we are designing care for an 87 year old female, who has been diagnosed with decreased mobility and a urinary tract infection.
The hospital she presented to performed x-rays which confirmed osteoarthritis (severe). Her other co morbidities include; osteoporosis, paroxysmal atrial
fibrillation, vestibular dysfunction and peptic ulcer disease. The care plans nursing diagnosis relate to her chronic conditions and their disease processes.
The patient goals are aimed at improving her quality of life and will be actioned through the nursing interventions we implement. To be successful at
achieving these goals we will need to evaluate the outcomes. We may need to alter our interventions along the way and re-evaluate the outcomes to be
successful in achieving our final goals.
4
Assessment
Planning /Implementation
Evaluation
Nursing Diagnosis
Expected Outcome –patient goal
Nursing Interventions
Rationale
Outcome Assessment
1. 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 out a pain
assessment and treat the
pain accordingly.
Pain limits mobility and
is often exacerbated by
movement (Ackley &
Ladwig, 2008)
Patient verbalises reduced
pain on mobilisation.
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
To empower patients
and improve their
knowledge with regard
to their medications,
The patient verbalises the
importance of their
medication regime and
repeats back their
5
2. 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 strength
before being discharged
from the hospital.
medications with her
disease process.
which optimises the
likelihood of patients to
take their medications
(Nurit, Bar Cohen, &
Zelker Revital, 2009).
understanding of the
education session. Patient
may need regular
prompting to take
medications due to short
term memory issues.
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
treatment (Blake &
Fogelman, 2007).
These scans are also
used to measure any
improvement in bone
density once
interventions have
been put in place
(Blake & Fogelman,
2007).
Continuous bone density
scans in order to determine
an improvement in bone
density and strength.
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
Monitor the patient’s diet
and make sure that they are
well educated on the foods
that are beneficial to bone
strength.
6
therefore increase their
strength (Stransky &
Rysava, 2009).
Administer calcium and
vitamin D supplements.
Administering calcium
and vitamin D
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).
Make sure that the patient
is taking their supplements.
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
Let the patient tell you
about osteoporosis and the
treatments to prevent
further progression and
improve bone density.
7
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 treatment plan
(Nielsen et. al, 2010).
3. Self-care deficit
related to limited
mobility due to severe
OA.
Patient is able to show the
level of functioning in the
following activities such as
bathing, dressing, feeding
and toileting. Also patient
demonstrates the ability to
use assistive devices.
Educate the patient about
the variety of assistive
devices used in home for
bathing, dressing and
toileting such as grip bars
in shower, long handled
zipper device, reacher,
raised toilet seat or grip
handle around toilet.
To increase the
patient’s sense of
control over her life and
to improve self-care
ability (Carpenito, L. J.,
2009).
Monitor the patient’s
activities and record them in
charts.
Schedule the activities in
between to provide
adequate rest periods.
To decrease
exhaustion as it
decreases motivation
for self-care activities
(Brown & Edwards,
Assess the patient’s selfcare activities and review
the patient’s feelings
whether she feels tired,
restless or not.
8
2009).
Refer to the occupational
therapy for instructions in
conserving energy
techniques and use of
assistive devices.
Occupational therapy
provides specific
instructions and further
assistance if required
(Carpentio, L. J., 2009).
Refer to the notes written
by occupational therapist
and assess the patient.
Discuss with family
members the changing
family processes resulting
from the patient’s illness.
Limited mobility
associated with the
chronic disease
interferes with the
client’s ability to care
for herself, her family
and home which
disrupts family
functioning (Ralph, S.
S. & Taylor, C. M.,
2007).
The family are adopting
themselves with the chronic
disease of the patient.
Discuss the importance of
promoting client’s self-care
at an appropriate level
with the family.
Maximum self-care
activities promote
positive self-esteem
and reduces the
feelings of
powerlessness which
leads to effective family
functioning (Ralph, S.
S. & Taylor, C. M.,
2007).
Ask the patient and family
to verbally give response
about coping with the
present condition of the
patient.
9
4. 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).
A reasonable goal is set
based on the patient’s
capabilities.
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).
All necessary advices are
available to the patient if
they are needed to achieve
the goal of being
independent and confident
in performing her ADL’s.
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).
Assess the patients
understanding of tasks to
be completed and with a
routine she will more than
likely comply with the tasks.
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)
Modifications help the
patient to be safe and at the
same time independent with
activities of daily living.
10
5. Potential constipation
during hospital stay
due to decreased
mobility and
analgesic
medications.
Patient will maintain
regular to substantial
bowel motions during her
hospital stay.
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).
With family encouragement
the patient builds up a
confidence that they can do
specific tasks. Asking the
family questions to see if
they feel she has improved
in confidence to perform
tasks.
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).
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
The patient is more
likely to be
apprehensive of
mobilising when there
is strong pain involved
11
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.
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).
Encourage fluid intake, 6-8 Adequate fluid intake is
glasses per day
necessary to prevent
hard and dry stools that
are difficult to pass
(Eoff & Lembo, 2008).
Use a fluid balance chart to
monitor fluid intake and
output.
Encourage oral intake, a
diet high in fibre.
When fibre reaches the
colon, it absorbs water
forming 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,
These soften stool,
Assess patient’s bowel
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suppositories, and
enemas ordered or when
required.
13
lubricate intestinal
mucosa and help
peristalsis (Gulanick &
Myers, 2007).
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).
Conclusion
In caring for our patient with her diagnosed chronic conditions we individually came up with nursing diagnoses that we believed
would affect her daily life. We believed her main issues would relate to pain, weakness, self-care deficit, potential risk for
constipation due to immobility and analgesic medications. Most of our interventions were based around education and how we
could support our patient to live an improved quality of life. In developing nursing interventions we looked at diet, assessments,
involving the patient’s family and referral to other health services within the multidisciplinary team. We were focusing our care
around a patient centred approach to ensure; that we involved the patient and their significant others in the development of her care
plan. As this will encourage the patient’s compliance, independence and will hopefully give our patient family support, as they were
too involved in the care plan process.
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