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Nursing Care Plan CC

By kaybn12345 Mar 02, 2015 1086 Words
Running Head: NURSE CARE PLAN EXERCISE

Nurse Care Plan Exercise
School of Nursing

NURSING DIAGNOSIS (ACTUAL)
75-year old female Assessment:
Subj cues:
Usual pattern 1 movement/day.
States she goes 1-2 days w/out movement as a result used laxative. Has difficulty drinking 6-8 glasses of H2O a day.
Green leafy vegetables are a challenge due to poorly-fitted dentures. Has Hyperacidity and bloating.

Obj cues:
There are no objective cues.

NURSING DIAGNOSIS (ACTUAL)
Constipation R/T Insufficient fiber and fluid intake, laxative abuse, aluminum-containing antacids, and bowel change. Goal: Patient will eliminate or reduce constipation as evidenced by daily soft bowel movements within two weeks.

OUTCOMES
(Patient will)
INTERVENTIONS
(Nurse will)
RATIONALE for intervention
EVALUATION
1. Cognitive
Patient will state three ways to incorporate foods that are easy to chew and are high in fiber into her diet after seeing a dentist.

Instruct and encourage the patient about different foods that are high in fiber and easy for the patient to chew. Rationale: “Fiber is an important element in promoting healthy digestion. It improves the consistency of stool and enhances easy passage through the colon.” (Doenges et al., 2011 pp.202)

Patient has stated three ways to incorporate foods that are easy for her to chew and are high in fiber into her diet. 2. Psychomotor
Patient will see a Dentist.

The nurse will provide the patient will information on how to acquire dental care for new dentures. Rationale: “Loosening of dentures affect nutrient and food intake. It also determines other factors such as affecting ingestion, digestion, chewing, and swallowing” (Doenges et al., 2011 pp.202)

Patient has seen dentist.
3. Affective:
Patient will be willing to see a Nutritionist.
The Nurse will encourage patient about achieving nutritional goals and collaborate with Nutritionist to set nutritional goals. Rationale: “Nutritional goals will be made to increase the client’s dietary need of increased fiber intake by providing the client with alternate options that are easy for the client to chew” (Doenges et al., 2011 pp.202).

Patient has seen Nutritionist

NURSING DIAGNOSIS (RISK)
75-year old female Assessment:
Subj cues:
Hesitant go outdoors due to cracks in side walk and people whom roller blade. Has small difficulty going upstairs.
Still has some weakness of her affected side.
Showers by sitting on a plastic chair and hand-held shower head. Walks with a quad cane.
Obj cues:
The home has a combined living room and dining room with furniture that can be re-arranged. NURSING DIAGNOSIS (RISK)
Risk for Fall R/T weakness, obstructive environmental factors, age over 65, and use of assistive device (cane). GOAL: Patient will have no falls within 1 month.

OUTCOMES
(Patient will)
INTERVENTIONS
(Nurse will)
RATIONALE for intervention
EVALUATION
1. Cognitive
Patient will state three ways to reduce her risk for falls in her environment. Instruct the patient about the dangers of living in a cluttered environment and how it increases her risk for falls. Rationale: “Anything that blocks or limits a clear, straight path for ambulation can contribute to a person’s fall risk” (Gulanick, 2014, pp.65). Patient has stated three ways to reduce her risk for falls in her environment. 2. Psychomotor

Patient will see Physical Therapist for weakness.
The nurse will provide the patient with information on how to acquire physical therapy for weakness. Rationale: “Physical therapy evaluation can identify problem with balance and gait that can increase a person’s fall risk” (Gulanick, 2014, pp.65). Patient has seen Physical Therapist.

3. Affective
Patient will be willing to have her living space rearranged. The Nurse will encourage patient to reduce clutter in her living space and assist in making arrangements to have living space rearranged by family members. Rationale: Risk for falls are increased when environment contain obstructions and “Patients who are not familiar with the placement of furniture and equipment in their room are more likely to experience a fall” (Gulanick, 2014, pp.65). Patient living space has been rearrange and now has cleared passageways.

WELLNESS DIAGNOSIS
ASSESMENT:
Subjective cues:
Couple wants to maintain their independence to as long as possible. Couple is interested increasing their outside actives outside of the home. Son takes parents grocery shopping and other errands.

Son and Daughter have expressed an interest in enrolling Parents in senior center activities. Son and Daughter requested to discuss options with social worker. Daughter is willing to take a day off from work to take Mother to the Hairdresser. Objective Cues:

There are no objective cues.
NURSING DIAGNOSIS:
Readiness for enhanced family processes.
GOAL:
The Patient and her family will engage in an enhanced family process within 3 weeks. OUTCOMES
(Patient will)
INTERVENTIONS
(Nurse will)
RATIONALE for intervention
EVALUATION
1. Cognitive
The Patient and family will openly express feelings about the family and state three ways to enhance the dynamics of their family structure. Nurse will encourage Patient and Family to discuss openly the importance of developing strong family dynamics. Rational: This “Facilitates ongoing expressions of open, honest feelings and opinions, and effective problem solving” (Doenges et al., 2013, pp.329).

Patient and family openly expressed thoughts and feeling and have stated three ways to enhance family dynamics. 2. Psychomotor
Patient and Family will engage in relaxation and visualization exercises.

Nurse will encourage Patient and Family to engage in relaxation exercises for stress management. Rational: “Relaxation exercises, visualization, and similar skills can be useful for promoting reduction of anxiety and ability to manage stress that occurs in their lives” (Doenges et al., 2011, pp.329). Patient and Family have engaged in relaxation and visualization exercises. 3. Affective

Patient and family will be willing to identify potential ways that the patient can rely on Family for assistance. Nurse will encourage Patient and Family of the importance in identifying time where the Patient will need Family assistance. Rational: “Thinking ahead can help individuals anticipate helpful actions to handle or prevent conflict and untoward consequences” (Doenges et al., 2013, pp.329)

Patient and Family have identified potential ways Patient can rely on Family for assistance. Overall Evaluation: All outcomes were achieved, therefore the goal was achieved.

Reference:
Doenges, M. E., & Moorhouse, M. F. (2013). Constipation. Nursing diagnosis manual: planning, individualizing, and documenting client care (4th ed.,p.329). Philadelphia: F.A. Davis Co.

Doenges, M. E., & Moorhouse, M. F. (2011). Constipation. Nursing diagnosis manual: planning, individualizing, and documenting client care (4th ed.,p.). Philadelphia: F.A. Davis Co.

Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed. pp.65). St. Louis: Elsevier/Mosby.

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