Nursing Care Plan for Nursing Year 1
REHAB FACILITY (information)
Patient Name: Mrs. X
Code Status: DNR
Marital Status: Widowed
Medical Condition: Right Hip #
Meals: Regular Diet
Fluid Consistency: Regular Fluids
Eye opening: spontaneously
Best Verbal response: oriented
Best motor response: obey
- Take meds whole with apple sauce
- Adjust oxygen saturation flow to maintain saturation 90-95%
92 yo woman transferred from HRH for right periprosthetic hip #.
→ She had previous hip #, dementia with dn PD, fell unwitnessed, on Dec 28, 2022, while walking to the bathroom with her walker. Found to have right hip # and an abrasion to the scalp. Underwent ORIF for right periprosthetic hip #.
27/02/23 → Nutrition:
- Intake Appetite: Intake has been flactuatong → consuming 50-100% of most meals, receiving supplemental vitamin D, diet tech involved with menu selection
- Chewing/swallowing: recent FEES – tolerating regular diet well
- Bowel management: last charted BM+today, receiving scheduled lactulose & senna to assist with regularity
- Skin Integrity: Skin reported as being intact. Braden = 15
28/02/23 → Physiological
Received sitting up in chair
- 1 person assist
- Toileted x 1, incont x 1
- Took 15mls lactulose instead of 30 mls
- Assisted to bed at 2230 at her request
27/02/23 →Client progress: Continue to progress in therapy. Assist x1 with direct pivot transfer from bed to wheelchair. OT program initiated. PBP done this am; SBP elevated, asymptomatic of BP and with position changes
03/03/23 → Participated in PT yesterday: “Ambulation: 60 m with 1min standing break + 2min sitting break at halfway point. Steady gait” Seen up in wheelchair, comfortable
Speech and Language
SLP Focus: FEES Study
- Fibreoptic Endoscopic Evaluation of Swallowing was completed
- Equipment used: Olympus CV-170, flexible nasolaryngoscopy
- Procedure was well tolerated and no clear penetration /aspiration
1. What is the Primary Medical Diagnosis and other medical diagnosis
2. what kind of communication strategies should use, what is significant about the client’s condition, how can we provide care by one person or do we need help, how does our care connect with CNO standards of practice, how do we interact with the interprofessional team, eg. UCP?)
NURSING PROCESS STEPS (CLINICAL JUDGEMENT MODEL)
Assessment (Recognizing and Analyzing Cues)
a. Identify data found on Kardex/Client care summary relevant to the care.
b. Identify further data needed before providing client care.
Diagnosis (Prioritizing Hypotheses)
a. Generate Nursing Diagnoses relevant to client (remember to consider physiological and psychosocial needs).
Planning (Generating Solutions)
a. Identify goals or desired outcomes for the client, related to the nursing diagnosis identified above. This should describe the client response that we expect to achieve as a result of interventions (Goals should be SMART [specific, measurable, attainable, relevant, times] goals).
b. Describe with rationale the activities, including nursing interventions, required to provide care. List the activities in the order that we will complete them.
Implementation (Taking Action)
a. Identify specific equipment items that we would need to prepare to take to the bedside to provide the care we have planned above.
b. What would be any other communication strategies to be used during implementation of care for this client.
c. what safety factors do we need to consider while providing care for this client? (For client and For Nurse)
d. Identify and give rationale for the infection control practices that we would use while implementing this care?
e. While providing this care, what other assessments would you make?
Evaluation (Evaluating Outcomes)
a. For the goal/desired outcome identified above, describe how we will evaluate our intervention. (Evaluation should reflect the goal / outcome related to the nursing diagnosis)
a. Provide a progress note or consider significant data to be documented.
a. Consider how to communicate significant information with the interdisciplinary team. (eg. shift change, conference, physician, OT/PT etc.)