2. 2
Care Plan
Table of Contents
Abstract 3
Assessment 4
Pathophysiology 4
FHP Analysis 5-9
Nursing Diagnosis 9
Planning 10
Implementation 10-16
Evaluation 16-17
Appendix A 18-19
References 20
Appendix B Attached
3. 3
Care Plan
Abstract
The purpose of this paper is to develop a patient care plan by utilizing the nursing
process, completing a physical assessment, and interviewing the patient. All interactions in this
paper took place at Abington Memorial Hospital between a patient and nursing student.
4. 4
Care Plan
Assessment
The student nurse began by receiving report during shift change. During report she was
able to gather some data and background information regarding her patient. The patient, ND, is
a 81 year old male that arrived on October 24, 2015 following a cerebral vascular accident. The
patient has a past medical history of chronic hypertension, hyperlipidemia, aortic aneurysm
w/o rupture of unspecified site, and dementia w/o behavioral disturbances. ND is 6.0 feet and
156 lbs. ND is drinking thickened liquids and following an ADA diet following the new diagnosis
of diabetes mellitus. An allergy assessment revealed reactions to the following medications,
morphine, penicillin, and sulfa drugs. ND had vital signs all WNL, Temperature 97.3, Blood
pressure 110/70, pulse 72, pulse ox was 96 on RA, and respirations were 18. His morning blood
glucose level was 175. The neurological assessment showed normal papillary response and
size, both eyes were 3mm, round, and brisk. His muscle strength was strong in all extremities
and he made purposeful movements. ND had a glasgow coma score of 14 where he only lost
one point for confusion.
Pathophysiology
ND had an admitting diagnosis of a cerebral vascular accident. According to an article on
strokecenter.org a stroke is, “the sudden onset of weakness, numbness, paralysis, slurred
speech, aphasia, problems with vision and other manifestations of a sudden interruption of
blood flow to a particular area of the brain. The ischemic area involved determines the type of
focal deficit that is seen in the patient.”
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Care Plan
Health Perception and Management Pattern
The student nurse asked ND questions regarding his health maintenance and patterns,
however he was confused and so information was not accurate. He told the student nurse he
lived at home with his wife and he thought he drove himself to the hospital. He could not
remember the events that took place leading up to his admittance to the hospital. The student
nurse later learned ND was brought to the hospital from Garden Springs where the care team
noticed ND having trouble speaking and dressing. ND had been at AMH for 10 days and the plan
was to discharge him back to Garden Springs later that day. ND general appearance was
unkempt, however he was in the hospital for 10 days and was not able to perform his usual
ADLs that he normally would perform at home. ND denies recently smoking, and claims to have
quit more than 10 years ago and used to drink socially. A chest x-ray showed cardiomegaly and
an ECG revealed A Fib with rapid ventricular responses and a right bundle branch block. ND
denies using any alternative treatment programs or supplements.
Nursing Diagnosis
Decreased cardiac output related to A-fib as evidenced by abnormal ECG.
Nutrition
ND had an appetite and didn’t notice any changes; he ate 75 percent of his breakfast
and 90 percent of his lunch. He denies any significant weight change in the past few months.
ND is on thickened liquids due to difficulty swallowing thin liquids. ND did not wear dentures
and had some missing teeth, but no loose or chipped teeth. All ND electrolyte labs were WNL.
6. 6
Care Plan
ND had a slightly lower albumin level of 3.0, and increased glucose of 175. His skin was pallor,
dry, flaky, and warm. He had bilateral +1 edema in ankles and feet, ecchymosis on his arms
most likely from previous IV site, and a (raised) rash covering his back. All of his skin was intact
and there were no pressure ulcers present. His capillary refill was greater than 3 seconds (4
seconds) on his toes. His lips were pink and moist and oral mucosa was moist and pink as well.
Nursing Diagnosis
Decreased tissue perfusion related to disease process as evidenced by capillary refill greater
than 3 seconds.
Elimination Pattern
ND has an indwelling catheter that was inserted on 10/26, despite having the catheter he is still
retaining urine and having suprapubic pain when moving and with palpation. A bladder scan
revealed 111 ml of urine in the bladder. His last BMwas 11-1, he did not have GI any
complaints, and he had bowel sounds in all 4 quadrants. His abdomen was round, distended,
and tender. Bun and creatinine were WNL.
Nursing diagnosis
Pain related to bladder spasms as evidenced by retained urine and patient jumping and
grimacing in pain.
7. 7
Care Plan
Activity Pattern
ND needed assistance fromone person to perform ADLs. Upon discharge he will need
assistance with his care, but he will receive that from Garden Springs. He is able to walk with a
walker. He has dyspnea on exertion, and will require daily ROMto maintain adequate motor
function. ND had a irregular heart beat and distended neck veins. The student nurse was able to
palpate radial pulses, but not dorsalis pedis. The student nurse obtained a Doppler to locate
pedal pulses; the right pedal pulse was difficult to locate with the Doppler. ND had easy, but
shallow respirations, his chest was symmetrical, no cough, and his lungs were clear. His lab
results showed low RBC (3.71) and H+H (10.6& 34.9%). WBC and platelets were WNL.
Nursing diagnosis
Activity intolerance related to the disease process as evidenced by dyspnea on exertion.
Risk for falls related to unsteady gait
Sleep Rest Pattern
ND stated he did not have any trouble falling asleep, staying asleep, and he sleeps at least 8
hours a night. He does not take any naps or use sleep aids. He watches TV to relax before he
goes to bed.
Nursing Diagnosis
Risk for disturbed sleep pattern related to frequent care during hospital stay.
8. 8
Care Plan
Cognitive Pattern
ND was awake and alert, but he was not oriented to time and place. His hearing was normal
and he wore eyeglasses that were at his bedside. His speech was slightly slurred, but his
language was appropriate and logical. A pain assessment revealed he had an aching pain 8/10
in the suprapubic region with movement and palpation. He expressed his pain by jumping and
grimacing when palpated. ND was given a B&O suppository to help relieve bladder spasms and
decrease the pain.
Nursing Diagnosis
Pain related to bladder spasms and retained urine as evidenced by jumping and grimacing when
palpated as well as the patient complaints.
Self Perception Pattern
ND seemed hopeful for a good prognosis and was calmand cooperative for the student nurse.
He showed anxiety about the pain and he stated he did not want to go home until someone
relieves the pain. He was willing to comply to all treatments and procedures and his only
concern was the suprapubic pain.
Nursing Diagnosis
Anxiety related to going home with pain as evidenced by patient stating, “I don’t want to go
home with this pain, please figure out what this pain is. I can’t go home like this.”
9. 9
Care Plan
Role Relationship Pattern
ND is married and has four girls that are grown, but lives at Garden Springs. He is a retired
mechanical draftsman. ND was a little disoriented and this information was difficult to assess.
His Erikson stage would be integrity vs. despair. He didn’t seemto have many worries and he
talked happily about his family. He didn’t seem to want to go into detail about his work and
kind of brushed off the conversation.
Nursing Diagnosis
Altered family process related to disease process as evidenced by needing to move to LTC
facility.
Coping/ Stress Pattern
ND was afraid of going home with pain in his abdomen. He was very accepting, calmand
cooperative with procedures and treatments.
Nursing Diagnosis
Fear related to going home with unresolved pain as evidenced by patient stating he was
worried about going home with pain.
Value Belief Pattern
ND was Lutheran and did not have any requests to meet his religious needs. He did not specify
and restrictions of conflicts with regards to religion and treatments. He is not an organ donor.
Nursing Diagnosis
10. 10
Care Plan
Risk for impaired religiosity related to aging
Nursing Diagnosis
Knowledge deficit related to the disease process of diabetes as evidenced by
uncontrolled blood glucose levels and recent diagnosis.
Planning
Due to ND’s recent diagnosis of diabetes he will need extensive teaching about the
disease process and how to prevent further damage and complications to the body. He will
need to adjust to many diet and exercise changes in order to maintain lower blood glucose.
Interventions
Short Term Goal: At 7 am the patient will select appropriate breakfast food following a ADA
diet
1. The student nurse will teach carbohydrate counting to ND; he can have 45-60 grams of
carbohydrate at a meal. The quickest way to count carbs is by looking at the food labels and
looking at the total grams of carbohydrate. Many fresh foods don’t have labels so the student
nurse will give ND a guide.
For example there is about 15 grams of carbohydrate in:
1 small piece of fresh fruit (4 oz)
11. 11
Care Plan
1/2 cup of canned or frozen fruit
1 slice of bread (1 oz) or 1 (6 inch) tortilla
1/2 cup of oatmeal
1/3 cup of pasta or rice 4-6 crackers
1/2 English muffin or hamburger bun
1/2 cup of black beans or starchy vegetable
1/4 of a large baked potato (3 oz)
2 Tbsp light syrup 6 chicken nuggets
1/2 cup of casserole
1 cup of soup
1/4 serving of a medium French fry
Rational: “Carbohydrate counting in=s a meal planning technique used to keep track of the
amount of carbohydrate eaten with each meal and per day. Often patients are advised to limit
carbohydrates to a predetermined number.”(Lewis 1167) By tracking and limiting
carbohydrates patients are able to maintain normal blood glucose levels more efficiently.
2. The student nurse will teach ND how to use create my plate app to follow a diabetic diet. The
student nurse will encourage fresh fruit to help satisfy sweet cravings and she will teach ND to
avoid sweetened drinks such as soda.
12. 12
Care Plan
Rational: “This simple method helps the patient visualize the amount or vegetables, starch, and
meat that should fill a 9 in plate.” (Lewis 1167)
3. The student nurse will teach the patient to limit alcohol consumption, one drink a day for
women and two drinks per day for men. The student nurse will explain that alcohol should be
consumed with food and recommend using sugar free mixes and drinking dry, light wines.
Rational: “Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver.
This can cause severe hypoglycemia in patients on insulin or oral hypoglycemic medications
that increase insulin secretion.” “Alcohol should be taken with food to reduce risk of nocturnal
hypoglycemia.” “Carbohydrate taken with the alcohol (mixed drink) may raise blood glucose.”
(Lewis 1166)
Short Term Goal: At 7pm the patient will demonstrate proper technique to monitor blood
glucose
1. The student nurse will teach proper hand washing during Am care and before lunch
Proper Hand Washing
1. Turn on water
2. Soap your hands and scrub for 20 seconds making sure to get in the webbing and under nails.
3. Rinse hands
4. Dry hands
5. Take towel and turn off tap
13. 13
Care Plan
Rational: “A patient with diabetes is more susceptible to infection because of a defect in the
mobilization of white blood cells and impaired phagocytosis by neutrophils and monocytes.”
(Lewis)
2. The student nurse will perform a morning blood glucose and afternoon blood glucose to
prepare the patient to be able to demonstrate self monitoring. The student nurse will explain
the steps of the process and provide written steps with pictures for the patient to review.
Self monitoring Steps
1. Wash hands
2. Place the lancet in the penlet lancing device
3. Use the side of the finger pad to obtain blood sample. (There are fewer nerves along the
side)
4. Set penlet device to make sure puncture is deep enough, but not too deep that it causes pain
and bruising.
5. Obtain sample and follow monitor instructions
6. Record results and compare with personal target blood glucose goals.
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14. 14
Care Plan
Rational: Self monitoring is a critical part of diabetes management. By providing a current blood
glucose reading, SMBG enables the patient to make decisions regarding food intake, activity
patterns, and medication dosages. It also produces accurate records of daily glucose
fluctuations and trends, and it alerts the patient to acute episodes of hyperglycemia and
hypoglycemia.”(Lewis 1168)
3. The student nurse will teach hypoglycemia and hyperglycemia symptoms
Hypoglycemia
Confusion Dizziness
Feeling shaky Hunger
Headaches Irritability
Pounding heart; racing pulse Pale skin
Sweating Trembling
Weakness Anxiety
15. 15
Care Plan
Hyperglycemia
Increased thirst Headaches
Trouble concentrating Blurred vision
Frequent peeing Fatigue (weak, tired feeling)
Weight loss Blood sugar more than 180 mg/dL
Rational: The patient should be aware of these symptoms to prevent acute complications of
DM. “Acute complications arise from hyperglycemia and hypoglycemia. It is important for the
health care provider to distinguish between hyperglycemia and hypoglycemia because
hypoglycemia worsens rapidly and constitutes a serious threat if action is not immediately
taken.”(Lewis 1174)
Long Term Goal: The patient will have an A1C less than 8% at next doctor appointment
1. The Student nurse will teach the patient to self administer insulin injections.
1. Wash hands thoroughly
2. Inspect insulin bottle before using it, proper type, concentration, and expiration date.
3. If cloudy gently roll the insulin in the palms of hands to mix solution
4. Select proper injection site, back of arms, abdomen, buttocks, or thighs.
5. Clense skin with soap or alcohol
6. Pinch up skin and push needle straight in, if thin or using 5/16 needle you may need to use 45
degree angle.
7. Let go of skin, leave needle in place for 5 seconds to ensure all insulin has been injected.
16. 16
Care Plan
8. Destroy and dispose of single use syringe safely.
Rational: The steps to administration should be taught to new insulin users and reviewed with
patients already using insulin. “Never assume that because the patient already uses insulin, he
or she knows the proper technique. The patient may not have understood prior instructions, or
changes in eyesight may result in inaccurate preparation.”(Lewis 1160)
2. The student nurse will teach the patient how to maintain an exercise program. There are
many activities that are beneficial for health promotion. It is important to choose activities that
are enjoyable for the patient to increase the
success of the exercise program.
Rational: “Regular, consistent exercise is an
essential part of diabetes and pre-diabetes
management. The ADA recommends that people
with diabetes perform at least 150 min/wk (30 minutes, 5 days/wk) of moderate-intensity
aerobic physical activity.” (Lewis1167)
3. The student nurse will instruct the patient to carry medical identification at all times so
inform others that he or she has diabetes in case of an emergency. Also if traveling teach the
17. 17
Care Plan
patient to get up at least every two hours special arrangements for needles and snacks may be
needed if traveling by plane.
Rational: “Police, paramedics, and many private citizens are aware of the need to look for this
identification when working with sick or unconscious persons. An identification card can supply
valuable information, such as the name of the health care provider; the type of diabetes; and
the type and dosage of insulin, noninsulin injectable agents, or OAs.”(Lewis 1173)
Evaluation
ND was able to meet his first goal of choosing appropriate breakfast selections, such as an
whole wheat English muffin, an apple, and coffee. He was able to count this as 45 carbs using
the chart the student nurse provided, 30 carbs for the entire English muffin and 15 for the fresh
fruit. The interventions for this goal were appropriate and were efficient in meeting the goal.
ND was able to meet his second goal of self monitoring his blood glucose. He understood the
need for hand washing first, to prevent infection. The pictures and two prior demonstrations
were helpful in meeting the goals in a reasonable time. The long term goal will be assed at a
later time. The student nurse is hopeful that if the patient is compliant with the diet, exercise,
and medication programs then he will meet his goal of having an A1C less than 8%. The A1C
test will be helpful in determining whether or not the patient has been compliant with the
guidelines put in place. If the patient has not been compliant the programs will have to be
revaluated and changes may need to take place.
18. 18
Care Plan
Appendix A
Medications
Insulin aspart- NovoLOG
Class- Pancreatics
Indication- control of hyperglycemia in patients with type 1 or 2 diabetes mellitus.
Action- Lowers blood glucose by stimulating uptake in skeletal muscle and fat, inhibiting hepatic
glucose production.
Dose depends on blood glucose, response, and many other factors.
Dose for ND- 6 units SC AC
Side effects- hypoglycemia, erythema, pruritis, swelling, anaphylaxis.
*Before administering assess for hypoglycemia, monitor body weight periodically, assess for
allergies, and monitor blood glucose q 6hr during therapy. Double check doses and orders and
check expiration date.
Heparin
Antithrombotics
Indication- Prophylaxis and treatment of thromboembolic disorders including venous
thromboembolism, pulmonary emboli, a-fib, with embolization, acute and chronic consumotive
coagulopathies, peripheral arterial thromboembolism.
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Care Plan
Side effects- drug induced hepatitis, alopecia, rashes, urticaria, bleeding, HIT, anemia.
Dose- subcut, 5000 units every 8-12 hours
ND Dose- 5000 units every 8 hours
Atorvastatin- HMG-CoA reductase inhibitors
Indication- adjunctive mgt of primary hypercholesterolemia and mixed dyslipidemias. Primary
prevention of cardiovascular disease.
Side effects- dizziness HA, insomnia, weakness, chest pain, peripheral edema, blurred vision,
constipation, nausea, diarrhea, bronchitis, rashes, pruritus, myalgia, arthritis, ED,
Rhabdomyolysis.
Dose- 10-20 mg once daily
ND Dose- 20 mg daily
Metroplol -Beta Blocker
Indication: Treats HTN, angina, prevent MI, and MGT of HF*
Action: Blocks stimulation of beta 1 adgenergic receptors
Desired Effects: Decreases BP and HR
S/E Bradycardia, hypotension, HF, pulmonary edema, fatigue, bronchospasm, and decreased
libido.
20. 20
Care Plan
Before administration monitor BP and HR do not give if systolic is less that 100 or HR less than
60. Monitor daily weights.
B&O Suppository- Belladonna alkaloid and opium
Treats moderate to severe pain due to spasmof urinary tract
Anticholinergic and analgesic combination relaxes smooth muscles of urinary tract and relieves
pain.
S/E: blurred vision, constipation, dry mouth, difficulty urinating, fast pulse, and vomiting.
Diltiazem- calcium channel blocker
Indication: HTN, angina, prinzmetals angina, supraventricular tachyarrhythmias
Action: inhibits transport of Ca into myocardial and vascular smooth muscle cells resulting in
inhibition of excitation, contraction coupling, and subsequent contractions.
S/E anxiety, arrhythmias, HF, bradycardia, hypotension, peripheral edema, tachycardia, syncope
Monitor BP, HR, K levels, liver and renal functions. Do not give if systolic BP is less than 100 and
HR less than 60
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Care Plan
Refrences
Vallerand, April Sanoski, Cynthia. (2013) Davis’s Drug Guide for Nurses Thirteenth Edition. F.A.
Davis Company.
Berman. A., Snyder.S.( 2012) Fundamentals of Nursing Concepts, Process, and Practice
Pearson Education, INC.
Lewis. (2014) Medical surgical nursing Assessment and Management of Clinical Problems Ninth
Edition. Elsevier.
Web MD. 2015. Hyperglycemia and Diabetes. -****-
http://www.webmd.com/diabetes/guide/diabetes-hyperglycemia
