Practical Nursing Program

Humber ITAL Mini Care Plan Step 1 Analysis

Student Name: Loreta Doga
Clients Age
Initials

Living
Accommodatio
n

McCall Centre
for continuing
care

P. M

Date: March 6 7, 2014

Diet

Regular

Step 1 Assessment All Modes

Activity Level

Diagnosis
Problems

-End stage COPD

-Type 2 Diabetes
-Mild Dementia
-Polymyolgia rheumatica
-Acute stroke

Limited

Adaptive/Ineffecti
ve
Behaviours

+/-

Physiological (all systems)

Problem

Ventilation
-Respiration 18
-O2 sat: 96% on room air
-Breathing pattern normal
-No signs of respiratory distress such S.O.B, nasal
flaring, use of accessory muscles, tripod body position,
lip breathing, tachypnea or dyspnea.
-No tenderness over the chest; no pain reported by pt.
-No lesions, masses or lumps observed over chest
during inspection and palpation.
-Chest expansion limited, lower on the right side
-Crackles audible during expiration on right lung during
anterior and posterior auscultation.
-No cough present.

+
+
+
+
+
-

Impaired gas exchange r/t COPD

and impaired lung function.

Cardiovascular
-Temp. 36 degrees Celcius; pt complains of being cold
all the time
-BP 162/66
-Brachial pulse 61; weak
-Radial pulse 61; palpable
-Skin slightly cyanotic on both feet; cold to touch
-No signs of SOB
-No complaints of chest pain
-No guarding or agitation during assessment
-S4 sound present during auscultation of apical pulse
-No numbness/tingling sensation present within
peripheries
-Capillary refill less than 2 secs
-Hair distribution over peripheral limbs and pubic area
-uneven
-No lesions or ulcers present
-No edema present

Fluid & Electrolytes

+
+
+
+
+
+
+
+
+

Ineffective thermoregulation r/t

poor blood circulation to
extremities and lack of physical
activity.

Insufficient ventricle expansion

r/t hypertension.
Altered tissue perfusion r/t
poor blood circulation.

Last bowel movement March 5, 2014

Last urination 0820
Pt eats and drinks well
No I/O required
No signs of dehydration present
Mucous membrane inside pts mouth normal
Poor skin turgor

Nutrition

+
+
+
+
+
-

Constipation r/t limited mobility

and lack of physical activity.

Altered skin integrity r/t dry

skin and lack of moisturizing.
+

Pt on normal diet regime

Breakfast (6-7 March, 2014): pt had
-1 boiled egg
-2 slices of toast
-1 cup of milk
-1 cup of coffee w/ 2 sugars and 1 milk
250 300 ml of water with meds

Elimination
Last bowel movement March 5, 2014
Tenderness noted over LLQ on palpation
Bowel sounds present over all 4 quadrants
Bruises present around the belly button due to insulin
injections
No bruit present over abdominal aorta during
auscultation
Abdomen shape protuberant
Micturition: Last void 0820; no fowl smell, color clear,
yellow.

Skin Integrity
Skin color flushed on the body and slightly cyanotic on
extremities;
Poor skin turgor;
Dry skin all over body;
Scaly skin on both feet;
Temperature of skin cold to touch;
Bruises present around pts belly button;
Skin tear on pts second last toe on right foot;
No scars, rashes or skin tear on the body.

Activity & Rest

Pt well rested;
Ambulatory MSK weakness assisted walking
device needed when pt out of bed;
Balance poor;
Activity level little to none;
Pt refuses to get out of bed beside going to the
washroom and meal time;

+
+
+

Constipation r/t limited mobility

and irregular bowel habit.

Impaired skin integrity r/t poor

blood circulation and dry skin do to
lack of moisturizing.
Risk for infection r/t improper feet
care, skin tear and poor blood
circulation.

+
+
+
+

Risk for falls r/t impaired balance

and muscle weakness.
Risk for impaired skin integrity r/t
lack of activity and poor
circulation.
Self care deficit r/t limited
ROM, poor balance and lack of
motivation to get out of bed.

Pt able to use his walking device to go to the

washroom;
Pt able to rinse his mouth;
Assistance needed with AM care;
Limited ROM;
No assistance needed during meals;
Neurological Function
Oriented to time, place and person
Alert and mostly able to interact during a conversation;
Normal facial expressions (smiles, frowns);
Able to clench teeth and jaw;
No tingling or numbness present;
Poor balance assisted walking device needed;

+
+
+

Risk for injuries r/t poor balance

and dementia.

+
+
+

+
The Senses
Vision and hearing normal;
Able to respond to touch and pain;
Able to distinguish between hot and cold, and responds
well to temperature changes.

+
Self-Concept
Positive attitude; aware pf his dependancy.
Cooperative with AM care, during medication
administration and meals.

Impaired role function r/t physical

and psychological clinical

conditions.

Role Function
Father of seven and husband;
Unable to fulfill his role as a father and a husband.

Interdependence

Self care deficit r/t limited

physical activity and dementia.

Dependable on others care;

Very limited daily living activities.

Humber ITAL PN Nursing Care Plan Step 2 Analysis

Student Name: Loreta Doga
Date: March 6-7, 2014
Medical Diagnosis (P. M -82): End stage COPD; Type 2 diabetes; Mild Dementia; Polymyolgia
rheumatica; Acute stroke
Allergies: No known allergies

Report Day 1:

Pertinent Data:

Pts skin is dry. Pain in his little toes and second last in his right foot due
to nail cut deep.
Priority Day 1: Chart pts problem for doctor to see if any treatment is
necessary to avoid infection. Inform nurse in charge about pts problem.

BP: 162/66
Pulse 57
O2sat: 96%
T: 36 C
Pain: 3/10

Report Day 2:

Pertinent Data:

Doctor assessed pt and ordered Vaseline to apply daily.

BP: 189/69
Pulse 61
O2sat: 95%
T: 35.8
Pain: 1/10

Priority Day 2: Keep pts skin soft and monitor changes on pts skin
integrity.

Nursing (Client) Problem (1): Skin damage on toes and dry skin on pts feet
Immediate Stimuli: Nail cut too deep and lack of moisturizing
Contributory Stimuli: Pt suffers from Type 2 diabetes
Nursing Diagnosis (1): Risk for infection r/t deep cut of nails and Type 2 diabetes

Expected Outcome(s)

Target
Date(s)

1. Stop the pain on pts toes

2. Prevent infection
3. Keep pts feet clean
4. Improvement of the skin on pts feet
5. Keep pts skin intact

6.3.14
6.3.14
6.3.14
7.3.14
Always

Nursing Interventions (Minimum 5)

1. Chart, report pain to the nurse in charge and administer analgesic.
2. Monitor pts feet for any changes regarding skin integrity, especially injured toes.
3. Wash and dry pts feet well; change socks every day.
4. Make sure to give to the pt the proper care regarding his feet and apply Vaseline daily.
5. Stress the problem (through the floor staff) to the person who takes care of pts nails to avoid deep
cutting.
Community Resource: (related to clients needs): Staff of personal care on the floor; doctor, PSW
and nurses.