Lisa Chee

NURS360
Professor KaUa
December 01, 2014
Concept Map Care Plan (WK04 Patient)
Desired Outcomes
Imbalanced Nutrition: Less than Body
Requirements
1. Pt verbalizes and demonstrates selection
of foods or meals
Evaluation: Goal partially met. Pt verbalized
that she does not like the food in the hospital
and that she has no appetite. Pt stated she did
not like the type of ham used in her
sandwich. Pt verbalized that she enjoys
eating papayas and bananas. Pt did not state
additional food preferences.
Infection/ Impaired Tissue Integrity
1. Pt receives stage-appropriate wound care,
experiences pressure reduction and has
controlled risk factors for prevention of
additional ulcers
Evaluation: Goal met. Pt received stageappropriate wound care w/ calmoseptine
lotion to stage II pressure ulcer to coccyx,
and antibiotics as ordered. Pt was provided
frequent position changes (Q2H) and
pressure relieving devices (while in bed). Pt
also got OOB into her chair for a few hours
during my shift. Frequent brief assessment
and changes provided.
Fatigue
1. Pt verbalizes reduction of fatigue AEB
reports of increased energy and ability to
perform desired activities
Evaluation: Goal met. Pt stated she had been
experiencing difficulty sleeping the night
before. During my shift, pt displayed
increased energy and motivation to complete
PT/OT. Pt was enthusiastic and asked for
assistance to get OOB into her chair during
my shift.
Pain
1. Pt reports satisfactory pain control at a
level less than 3 to 4 on a 0 to 10 rating scale
Evaluation: Goal met. Pt denied pain at rest,
but reported dull pain 2/10 to abdomen post
OT. VS stable. Pt declined PRN pain meds.

Interventions
Imbalanced Nutrition: Less than Body Requirements
1. Daily weights
2. Strict I&O
3. Monitor laboratory values that indicate nutritional well-being or
deterioration (e.g. serum albumin, transferrin, RBC and WBC
counts, serum electrolytes)
4. Administer bolus doses of Jevity 1.2 via J-tube as ordered
5. Administer 1 can of Resource Breeze 3x/day PO for nutritional
support as ordered
6. Assess patients food preferences

Infection/ Impaired Tissue Integrity

1. Use objective tool for pressure ulcer risk assessment (Braden
scale)
2. Assess the amount of shear and friction on the patients skin
3. Describe the condition of the wound (color, odor, and presence of
necrotic tissue, visibility of bone, muscle or joints, exudates)
4. Assess patients pain level
5. Change the patients position frequently (Q2H)
6. Provide wound care with Calmoseptine lotion
7. Provide pressure relieving devices
8. Administer antibiotics (e.g. metronidazole, micafungin, nystatin,
ceftriaxone) as ordered
9. Frequent brief changes

Fatigue
1. Assess the patients description of fatigue: timing, severity,
relationship to activities and aggravating/ alleviating factors
2. Assess for possible causes of fatigue
3. Assess the patients ability to perform activities of daily living
(ADLs)
4. Evaluate lab/ diagnostic test results (e.g. BG, H/H, BUN, O2)
5. Stress the importance of frequent rest periods
6. Promote adequate nutritional intake
7. Minimize environmental stimuli, especially during planned times
for rest and sleep
Pain
1. Assess and reassess (post pain meds) pain characteristics
2. Monitor s/s a/w pain (e.g. BP, HR, temperature, color and
moisture of skin, restlessness and ability to focus)
3. Administer PRN acetaminophen-codeine for pain relief
5. Provide rest periods to facilitate comfort, sleep and relaxation.
6. Provide nonphramacological methods of pain relief

Insomnia
1. Pt achieves optimal amounts of sleep, AEB
rested appearance, verbalization of feeling
rested and improvement in sleep pattern
Evaluation: Goal partially met. Pt verbalized
difficulty falling asleep last night. Pt napped
for thirty minutes during my shift. Continue
to assess.
Decreased Cardiac Output
1. Pt maintains adequate cardiac output AEB
strong peripheral pulses, systolic BP within
20 mm Hg of baseline, HR 60 to 100
beats/min with regular rhythm, urinary
output >/= 30 mL/hr, warm and dry skin,
normal LOC, and eupnea w/ absence of
pulmonary crackles
Evaluation: Goal partially met. Pt had weak
peripheral pulses to BLE, r/t 2+ pitting
edema to BLE and h/o CHF. VS WNL, UOP
>/=30 mL/hr. Skin is warm and dry to touch.
Pt is A&O x3. Eupnea and absence of
pulmonary crackles noted. Cap refill <3
seconds. Metoprolol and Felodipine held d/t
low BP of 108/58, primary RN notified.
Impaired Physical Mobility
1. Pt performs physical activity within limits
of disease
Evaluation: Goal met. Pt displayed increased
energy and motivation to complete PT/OT. Pt
was enthusiastic and asked for assistance to
get OOB into her chair during my shift. Pt
utilized call light when she required
assistance.

Self Care Deficit

1. Pt safely performs (to maximum ability)
self care activities
Evaluation: Goal met. Pt displayed increased
energy and motivation during OT. Pt was
engaged during OT session and learned how
to put on/take off her shorts and to brush her
hair. Pt was enthusiastic and asked for
assistance to get OOB into her chair during
my shift. Pt requires moderate assistance
performing ADLs (e.g. toileting/ bathing/
hygiene), but was able to cleanse her own
face. Pt utilized call light when she required
assistance.

Insomnia
1. Assess current sleep pattern and sleep history
2. Instruct pt to reduce daytime napping and to increase daytime
activity
3. Encourage pt to follow as consistent a daily schedule for retiring
and arising as possible

Decreased Cardiac Output

1. Assess rate and quality of apical and peripheral pulses, including
capillary refill
2. Assess BP, noting any orthostatic changes
3. Assess heart sounds for presence of S3 and/or S4
4. Assess RR, rhythm, and breath sounds
5. Assess skin color, temperature and moisture
6. Assess for complaints of fatigue and reduced activity tolerance
7. Administer B-blockers (e.g. Metoprolol)
8. Administer Calcium Channel Blockers (e.g. Felodipine)
9. Administer diuretics (e.g. Lasix)

Impaired Physical Mobility

1. Assess the pts ability to perform ADLs
2. Assess pts ability to perform ROM to all joints
3. Assess skin integrity
4. Encourage and facilitate ambulation
5. Encourage appropriate use of assistive devices
6. Provide a safe environment (e.g. bed rails up, bed in lowest
position, necessary items close by).
7. Perform passive or active assistive ROM exercise to all
extremities
8. Physical therapy
Self Care Deficit
1. Asses the pts ability to perform ADLs
2. Assess the pts need for assistive devices
3. Bathing/ Hygiene: Encourage the pt to bathe self as much as he
or she is capable of. Assist w/ completion of bath, only as needed.
4. Toileting: Evaluate or document previous and current patterns for
toileting.
5. Transferring/ ambulation: Encourage pt to use the stronger side
as much as possible (Rt side). Provide minimal/moderate assistance
as needed.
6. Allow the pt to work at own rate of speed

DISCHARGE PLAN/ PATIENT TEACHING

Pt will be discharged back to Kuakini Geriatric Care (KGC) for continued OT/PT rehabilitation for s/p Lt total hip
arthroplasy. Pt is widowed, but her main support system is her family members. She lives w/ her daughter. She has
11 children, her oldest son passed away. Her second oldest son is actively participating in her care. He visited her at
the bedside a few times during her hospitalization at WE-4. Pt requires moderate assistance with ADLs (e.g. bed
bath, oral care, peri care, dressing). Pt learned how to dress and brush her hair at her last OT therapy session. Pt is
incontinent and requires frequent brief changes. Pt is able to feed herself; however, she has poor PO intake. Pt will
require a CNA at KGC. Pt states her children are usually working or busy with their family; thus, a home care CNA
might be required once pt gets discharged from KGC to her daughters home. Pt will be discharged with a walker
and supplies for wound care (stage II pressure ulcer on coccyx). Pt utilizes a walker to get OOB into her chair;
moderate assistance is required since pt has a poor gait. Preferred pt teaching method is verbal and return
demonstration or verbalization.
Discharge planning and teaching reviewed w/ pt. Educated pt on her medication and their associated side effects.
Educated pt on pain management. Educated pt on pressure ulcer management (e.g. maintaining asepsis, proper
wound care, utilizing pressure relieving devices). Educated pt on hip precautions (e.g. do not sit or stand for
prolonged periods, do not cross legs beyond midline of body, do not bend hips >90 degrees). Educated pt on the
importance of increasing nutritional intake (e.g. essential for wound healing, maintaining adequate weight/ fluid and
electrolytes). Encouraged pt to participate in recording food intake utilizing a daily log and to f/u w/ a nutritionist.
Educated pt on s/s of bleeding or infection (e.g. redness, swelling, purulent drainage, fever, pain) to J-tube and
surgical site and informed pt to seek medical attention when this occurs. Educated pt on how to use ambulatory aid
(e.g. walker). Pt successfully demonstrated how to properly use a walker. Provided f/u instructions w/ PCP regarding
s/s low BP, syncope, another episode of coffee ground emesis, fatigue. There are no obvious cognitive, physical or
emotional barriers to learning at this time.

Resources:
Gulanick, M. and Myers, J. (2011). Nursing care plans: Diagnoses, interventions, and outcomes. St. Louis, Missouri:
Elsevier Mosby.