Practical

Nursing Humber ITAL Mini Care Plan

Step 1 Analysis
Date:
Week:
Living
Diet
Activity
Diagnosis Problem
Accommodation
Level

Student Name:
Clients Age
Initials
Long-Term Care
S.K
81
Step 1 Assessment All Modes

Physiological (all systems)

Ventilation
Diagnosis:
None
History:
None
Lifestyle:
Smoking, 60 years

Assessments:
O2Sat: 95%
R: 18 Rhythm: Steady
Breathing effort: Relaxed
Inspection:
Cough: None
Sputum: None
Symmetrical expansion: Yes
Auscultation:
Breath sounds:
o Bronchial: Present
o Vesicular: Present
o Bronchial Vesicular:
Present
Crackles: No
Wheezes: No
Medications:
None
Lab Values:
Total CO2: 26 mmol/L

Cardiovascular
Diagnosis:
Hypertention
History:
None
Lifestyle:
- smoker: Yes, 60 years
- Alcohol: No

Regular

Low

Adaptive/
Ineffective
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Pelvic fracture, HTN

Problem







-Patient at risk for COPD, heart
attack and cancer
-Patient at risk for perfusion, poor
oxygenation and ventilation

-Risk for poor cardiac output,
coronary artery disease,
hypertension and heart attack

- Patient at risk for COPD, heart

attack and cancer

Assessments:
P: 80 b/min and regular
BP: 150/67
O2Sat: 95% on room air
Capillary refill: less than 2 seconds
Inspection:
Skin color: pale and pink
Nail beds: pink
No pallor
No abnormal pulsations visible on
pericardium: yes
Auscultation:
S1 & S2 identified: yes
No murmurs
Palpation:
Pulses palpable:
o Dorsalis pedis: yes
o Radial : yes
Edema: feet and ankles
Medications: Dalterparin, ASA

Lab Values:
Troponin: 0.02 ug/L (Normal)
CK: N/A
CKMB: N/A
PTT: 24 s (Normal)
INR:1.1 s (Normal)

Fluid & Electrolytes
Diagnosis:
-None

History:
-Poor fluid intake

Lifestyle:
-Regular diet
-Incontinent

Assessments:
Amount of Fluid taken orally:
500 ml/day

Inspection:
-Urine x2/day: no strong odor

Palpation:
Skin turgor: Slow retraction
Edema: In feet and ankles

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-High blood pressure can cause a
risk of heart attack, HTN, coronary
heart disease
-Patient at risk for poor tissue
perfusion

-Can increase risk of poor circulation
and decrease elasticity of arteries
and veins
-Put patient at risk for internal
bleeding and hemorrhages

-Patient at risk for dehydration,
malnutrition and decrease in
electrolytes or electrolyte imbalance

-Puts patient at risk for loss of
bladder control, UTIs and rashes
due to urine and skin breakdown
-Patient at risk for dehydration,
decreased skin turgor, UTI and loss
of electrolytes

-Patient at risk for incontinence,

increased toxins in blood and UTIs

-Patient at risk for possible
dehydration
-Patient at risk of decrease in
circulation and fluid retention

-Patient at risk for cramping, nausea

Lab Values:
Na: 127 mmol/L (Abnormal)
Potassium: 3.8 mmol/L (Normal)
Chloride: 96 mmol/L (Normal)
Urea: 1.9 mmol/L (Abnormal)
Creatinine: 42 mmol/L (Abnormal)

Nutrition
Diagnosis:
-None

History:
- Poor appetite

Lifestyle:
-Regular food diet

Assessments:
W: 52.8 kg
Type of Diet: Regular
Appetite: Poor
Inspection: Symmetrical abdomen
Palpation: No hard areas or pain
Auscultation: Present bowel sounds
Medications:
-Pantoprazole
-Docusate Sodium

Elimination
Diagnosis:
Incontinent

History:
N/A

Lifestyle:
-Low fluid/food intake
-Low activity level

Assessments:
Urinary output: 300ml/day
Color: yellow Odor: none
Infection: None
Bowel Habits: Irregular
Abdomen: Symetrical
BS x 4 quadrents: Present
Inspect: Skin smooth no tears
Palpate: No pain or hardening
Auscultate: Bowel sounds present

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and muscle weakness

- Low creatnine levels increase the

patients risk for type two diabetes
-Patient is at risk for kidney failure

-Patient at risk for malnutrition,

fatigue and weight loss

-Patient at risk for malnutrition,
fatigue and weight loss

-Patient at risk for blurred vision,
nausea and dry skin
-At risk for skin rash, diarrhea and
cramping


-Patient at risk for renal failure and
UTIs






-Patient at risk for dehydration and
malnutrition
-Patient at risk for low muscle tone,
Bedsores and skin breakdown

-Patient at risk for UTI


Patient at risk for bowel obstruction,
constipation and fluid retention

-Patient may experience cramping,
stomach pain and nausea

Medications:
Docusate Sodium
Lab Values:
Creatnine: 42 Umol/L (Abnormal)
Urea: 1.9 mmol/L (Abnormal)
Sodium: 127 mmol/L (Normal)

Activity & Rest

Diagnosis:
Pelvic Fracture
History:
None
Lifestyle:
Rehab 1x/week
Occupational Therapy 3x/week

Assessments:
(Musculoskeletal Assessments)
-Poor weight baring
-Symmetrical strength
-Poor balance
-Pain in bed due to coccyx pain/pressure

Physiotherapy:
1x/week
Sleep:
Patient sleeps through the night till
morning
Patient sometimes wakes up
forgetting where they are

Skin Integrity
Diagnosis:
N/A
History:
N/A
Lifestyle:
Mobile

Assessments:
Skin integrity: Good
Wounds: None
Dressings: None
Inspection/Appearance: patients
extremities are dry
Skin Turgor: Slow retraction
Medications:
- None

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- Low creatnine levels increase the
patients risk for type two diabetes
-Patient is at risk for kidney failure

-Patient is at risk for decreased
mobility, discomfort and lack of
activity

-Puts patient at risk for falls

-Puts patient at risk for falls
-Patient at risk for coccyx skin
irritation increasing patients
discomfort and breakdown

-Puts patient at risks for falls due to
confusion

-Patient is at risk for skin tearing due
to dryness

-Patient is at risk for dehydration


The Senses
Diagnosis:
Dementia
Lifestyle:
Mental state impaired
Assessments:
Vision: Good
Hearing: Good
Speech: Good
Tactile: Good
Olfactory: Impaired
Assistive devices: Reading glasses
Pain: 5 on scale of 0-10

Medications:
ASA
Hydromorphone
Acetaminophen

Neurological Function
Diagnosis:
-Dimentia
History:
None
Assessments:
Mental Status: incompetent
Behavior: cooperative
Motor Function: operational
Strength in arms is equal bilaterally
Balance is inadequate for
ambulation
Tactile
Medications:
Doneprezil- Imporoves thinking
ability
Quetiapine- Antipsychotic


Endocrine Function/Reproduction
Diagnosis:
None
History:
None
Assessments:
Diabetes: N/A
BS: N/A
Lab Values:

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- Dementia places patient at risk for

confusion and anxiety.
-Mental impairment can put patient
at risk for confusion, anxiety and
falls

-Patient can experience an increased
risk towards hazardous situations
-Glasses places patient at risk for
falls
-Puts patient at risk for an increase
in vitals

-Patient at risk for extreme

discomfort and increased vitals due
to poor pain management
- Patient can experience stomach
cramping, nausea, vomiting,
discomfort
-Patient can experience nausea,
vomiting, lightheadedness, head ache
which can lead patient to feeling
uncomfortable
-Patient can be at risk of
experiencing lower back pain, adding
to patients current coccyx pain
-Dementia places patient at risk for
confusion and anxiety.

-Incompetency puts patient at risk
for confusion and anxiety, which
could result in falling if confused.


-Decreased balance ability puts
patient at risk for falls upon
ambulation.

-Low TSH levels puts patient

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TSH: 5.9 mIu/L

-creatnine: 42 Umo

at risk of anxiety, confusion,

vision loss, heart arrhythmias,
heart failure
-Low creatnine levels increase
the patients risk for type two
diabetes

Psychological Mode

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Self-Concept
Personal self:
Coping mechanism: Medication
Facial expression: Calm
Gender: Female
Age: 81
Interests to self: Low self concept,
no-one will care if I die, why will
they care if I die I use to be a very
smart woman, and now Im not

Role Function
-Widowed
-5 children
-Lives in VIVA retirement home
-Poor self concept
Interdependence
Nursing care
One person assist with ADL

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Problem


-Patient at risk for
dependency, addiction and
/or drug tolerance.

-Puts patient at risk for
depression and suicide



-Patient is at risk for
depression


-Patient is at risk for
depression


-Puts patient at risk for falls
with only one caregiver