Nursing Care Plan

Care Plan

Name:

Institution of Affiliation:

Student Name:

Date:

Possible Points: 100

Data Collection

Demographics:

Patient Initials: LA

Age: 63

Sex: Male

Race/Ethnic background: White

Primary Language: English

Religion: Christian

Current Diagnosis for Hospitalization:

Fall, hip fracture which happened today morning in his kitchen. He has not been admitted as it is his initial treatment.

Medical History:(Includes previous illness, surgeries, procedures, diagnostic tests and chronic conditions):

As per the patient, no medical history.

Social History:

Occupation: Unemployed

Education Level: Basic

Pandemic knowledge level: Understands the COVID-19 prevention measures and WHO guidelines

Pandemic’s influence on job: No influence

Based on your assessment until now describe if patient has any Cognitive (learning) limitations, and educational baseline:

The patient lacks knowledge and skills about different aspects of the health condition since he is uneducated.

Health Habits:

Smoking: Smokes meth

Alcohol: No history of taking alcohol

Illicit Drugs: Has a history of marijuana use

Exposure to Environmental Hazards: the patient is allergic (NKDA)

Exposure to Covid19/got tested/vaccinated? Negative for COVID-19 and not vaccinated

Diet: Consistent carbohydrate diet

Alternative therapies use: No alternative therapy use

Activity regimen: Ambulate TID with Assistance, using a walker

Health Maintenance:

Last Physical Exam: The patient weighs 54.8kg, Barden score of 21

Any Diagnostics done related to prevention: No available diagnosis

Familial Risk Factors:

Diabetes: No history of diabetes

Heart Disease: Not available

High B/P: Not available

Kidney Disease: Not reported

Cancer: Not reported

Stroke: Not reported

Seizures: Not reported

Other: No information about family health risk

Psychosocial Assessment:

Marital status/any issues you want to discuss: Separated

Role in family: Independent

Coping mechanisms: Stays independent life, receives help from family and friends

Support Systems: Family and friends

Stress factors: Socially isolated from the family which causes stress

Covid-19 related impact on stress, support system, and coping mechanisms: Being a divorcee, the patient suffers from loneliness and lack of social support.

Based on your assessment until now describe patient’s emotional status:

The patient suffers from loneliness due to social isolation. The COVID-19 pandemic and the divorce from the wife have resulted in anxiety. He has resorted to abusing drugs as that s the only way he will keep himself busy and emotionally stable.

Activity/Rest:

Leisure Time Activity

Sleep patterns: Spends most of the time sleeping during the day. Experiences insomnia at night.

Need any help with ADLS? Does not need any help to undertake activities of daily living (ADLS).

Based on your assessment until now describe patient’s mental status (alert, withdrawn, irritable):

From my initial assessment, there is no evidence that can link the patient to cognitive or learning difficulties. The patient looks withdrawn and irritated at the same time which can be explained as a result of lack of having the family close to him. Due to his isolation, he has developed repelling behavior as doesn’t want to be associated with other people. Prefers staying in exclusion. 

Review of Systems:

Subjective Assessment:

• General (Fever, chills, loss of taste, loss of smell, weight gain or loss, chronic pain):

Since the patient doesn’t often have appetite, he has lost weight and occasionally has fever, loss of smell and chronic pain from both feet.

• neuro (any headache, vision difficulty, hearing difficulty, swallowing difficulty, balance difficulty, history of seizure)

There is no history of headache nor any form of visual impairment from the patent. There are also no notable balancing difficulties nor swallowing of hearing challenges. Similarly, there is no notable history of seizures (Matchar et al.,2017).

• Cardio (chest pain, any pacemaker, any palpitations)

The patent doesn’t report any pain in the chest. Doesn’t use a pacemaker as there are no palpitations.

• Respiratory (SOB? Smoker? On O2?)

The patient occasionally uses meth. On the day of the accident, the patient admitted to have used meth earlier before the fall.

• GI (nausea, vomiting, nutrition, Last BM, diet)

The patent uses a diet that is consistent with carbohydrates. The patient has no complains of nausea, vomiting. The last BM was taken on 30^th April 2021.

• GU (any difficulty urination, retention issues, any other issues like incontinence)

The patient doesn’t demonstrate any urination difficulties or retention issues. Besides, there is also no issue with incontinence.

• Mobility: (daily activity? Any help needed)

The patient has not had any mobility difficulties previously until the day he experienced a fall. The patient has not been in need of any assistance with mobility.

• Skin (any wounds? Any redness?)

There are no wounds or redness on the skin at the time of the examination.

• Pain? Assess using a verbal scale and use tools like PQRST

Pain with activity 4-6/10, on the pain scale

Pharmacology (Total 60 points)

List Generic/Brand name, Dose, Route, Frequency	Therapeutic Classification And Mechanism of action	Why is this prescribed for this patient?	Side effects	Nursing implications	Is this medication a home medication, a temporary medication in the hospital or a new medication just added in patient’s regimen.
Chlorhexidine 0.12% 15ml, PO, liquid BID, use one hour after tooth brushing	antiseptic antibacterial agents. Woks	The drug is important as it inhibits bacterial growth at the place of the wound	It can result to bleeding. It can lead to swelling if not well applied	It is important to advice the patient about the complications that come with using this drug.	The medication provides a temporary measure in responding to the patient’s condition.
Lisinopril 20mg, PO daily	The drug belongs to angiotensin-converting enzyme (ACE) inhibitors and works by decreasing certain chemicals that tighten the blood vessels, so blood flows more smoothly	This drug is appropriate since the patient has a history of high blood pressure	It can cause dizziness, fatigue, low blood pressure and cough as well as high levels of potassium	It is important o closely monitor the patient for situations that may likely result in reduction of blood pressure before reduction in fluid volume	The medication is a temporary measure to fighting hypertension in the patient
Methadone 150mg, PO daily	The drug is a pain reliever and can be used for treating drug addition	The drug is applicable for this patient since he has pain and drug addiction problem	The drug results in withdrawal symptoms. Nausea; vomiting; constipation; anorexia; abdominal pain; drowsiness;	The nurses should be warry of the symptoms when administering the medication	The drug provides a temporary measure for the mental health condition of the patient
Acetaminophen 650mg, PO, q4hrs PRN for Temperature	The drug is a pain reliever. It works by reducing the production of prostaglandins in the brain	Since the patient is feeling pain, the drug acts as a pain reliever for the patient	The side effects of this condition include nausea, stomach pain, having persistent headache, dark urine and rashes as well as loss of appetite	The nurse must ensure safe administration, monitoring for efficacy and looking for possible adverse reactions	The drug provides a temporary measure in addressing the pain condition the patient is facing.

List OTC Medications/Herbs?:

Some of the home medications include Methadone, Lisinopril and Metformin

Do you see any polypharmacy or medication reconciliation issues?

There are no notable medical reconciliation issues to be addressed in the patient’s condition.

Pathophysiology (100points)

Read the Medical Diagnosis from your Medical Surgical book and complete shaded part of this worksheet. The unshaded section should be filled up based on the data you collected

Patient Initials:                      LA                                          Pt’s Age: 63

Diagnosis:

Normal changes of aging that may have increased risk for dx (5points) At 65, the patient could be having both mobility and visual challenges. Therefore, experiencing falls is quite likely for the patient. Research also indicates that the continued use of marijuana makes one unstable which could have contributed to the patient falling. Secondly, the patient has a history of hypertension and polysubstance abuse. Being hypertensive shows a high likelihood of the patient being inactive (Ang, Low & How, 2020). The low weight also shows that could be the patient doesn’t eat well and hence doesn’t have energy to undertake tasks on his own.

Definition of medical diagnosis: (5 points) Medical diagnosis is defined as the process which links the signs and symptoms that a patient has shown to a given condition that the patient could be suffering from. For the condition described for this patient, the diagnosis entails assessing for the possibilities of falls, hip fracture, hypertension and substance abuse. Looking at the symptoms presented by the patient can help to give a more narrowed focus of the condition the patient is suffering from especially after doing a differential diagnosis process.

10points for each section

Risk factors/Etiology	Patient’s risk factors/Etiology of patient’s disease (as per Data collection) Drug abuse – the patient uses polysubstance and marijuana which may affect his stability Too much intake of carbohydratesAdvanced age which increases instabilitySensory deficitsToo much sedentary lifestyle/ isolation and mental health condition could as well contribute to hypertensionHypertension can as well be due to genetic inheritance
Pathophysiology (brief description of changes that occur in involved system/s).	Patient falls often occur in elderly patients due to aging. The muscle tissues tend to be weak and the patient cannot sustain himself properly. Physiological studies also show that the condition could be as a result of too much intake of marijuana. The hip fracture shows that the patient fall was to a big scale and can easily result in other chronic conditions.
Clinical Manifestations (Typical signs and symptoms expected).	Signs and Symptoms Manifested by Patient as per patient The X-ray process conducted showed that the patient has a fracture of the base of the right femoral neck. Secondly, there was a fracture that was also just below the acetabulum.
Diagnostic Studies (Lab tests, X-rays, Scans, etc) to confirm diagnosis	Diagnostic tests done on patient as per patient The first lab test was CBC which was normal, the general chemistry was also known. There was a Hip Xray test on the pelvis which showed that the patient had a fracture on the pelvic region. There was a CT Abdomen plus Pelvis with V contrast.
Expected Treatments	Patient’s actual treatments as per patient The expected procedural treatments include Percutaneous Treatment Internal Fixation right hip  Right Intertrochanteric Hip Fracture Implants

Nursing Diagnosis One Physiological (32 points)

Assessment 5points	Nursing Diagnosis 5 points	Goals/Expected Outcomes 2 per diagnosis 5points/2.5 for each	Therapeutic Nursing Interventions 3 interventions/goal 6 points /1 per intervention	Rationale for Nursing Intervention(cite source, APA format) 6 points /1 per intervention	Evaluation   Have the goals been met?   5points/2.5 for each
Subjective Data:	Diagnosis#1   R/T     AEB	Outcome:   1.   By___________   2.   By____________	1. 2. 3.         1. 2. 3.	1. 2. 3.         1. 2. 3.	1.   By_____       2.   By_______

Nursing Diagnosis Two Physiological (32 points)

Assessment 5points	Nursing Diagnosis 5 points	Goals/Expected Outcomes 2 per diagnosis 5points/2.5 for each	Therapeutic Nursing Interventions 3 interventions/goal 6 points /1 per intervention	Rationale for Nursing Intervention(cite source, APA format) 6 points /1 per intervention	Evaluation   Have the goals been met?   5points/2.5 for each
Subjective Data:	Diagnosis#2   R/T     AEB	Outcome:   1.   By___________   2.   By____________	1. 2. 3.         1. 2. 3.	1. 2. 3.         1. 2. 3.	1.   By_____       2.   By_______

Nursing Diagnosis Three Psychosocial (32 points)

Assessment 5points	Nursing Diagnosis 5 points	Goals/Expected Outcomes 2 per diagnosis 5points/2.5 for each	Therapeutic Nursing Interventions 3 interventions/goal 6 points /1 per intervention	Rationale for Nursing Intervention(cite source, APA format) 6 points /1 per intervention	Evaluation   Have the goals been met?   5points/2.5 for each
Subjective Data:	Diagnosis#2   R/T     AEB	Outcome:   1.   By___________   2.   By____________	1. 2. 3.         1. 2. 3.	1. 2. 3.         1. 2. 3.	1.   By_____       2.   By_______

Patient Teaching Plan

Student Name:                                                                                                                            Date: 14^th May 2021.

Patient Initials: LA                                                                                                           

Patient’s Diagnosis: Diagnosed for fall, hip fracture and hypertension.

References

Ang, G. C., Low, S. L., & How, C. H. (2020). Approach to falls among the elderly in the community. Singapore medical journal, 61(3), 116.

Matchar, D. B., Duncan, P. W., Lien, C. T., Ong, M. E. H., Lee, M., Gao, F., … & Eom, K. (2017). Randomized controlled trial of screening, risk modification, and physical therapy to prevent falls among the elderly recently discharged from the emergency department to the community: the steps to avoid falls in the elderly study. Archives of physical medicine and rehabilitation, 98(6), 1086-1096.