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Mrs. Walesa: A Nursing Care Plan

Student Name: Meggan Sutherland, 0260365
Norquest College
NFDN 1002-SecD01
Assignment # 2: Nursing Care Plan
Instructor: Liz Anderson
April 15th, 2013

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Nursing Assessment Tool: A Systems Approach

SYSTEM
Respiratory System

Cardiovascular
System

ASSESSMENT

Respiratory rate and rhythm

Chest movements
Breath sounds
Shortness of breath

Pulse rate and rhythm

Heart sounds

Nervous System

Blood pressure
Nail bed colour
Signs of oxygen deprivation
Tissue turgor
Edema
Lab test findings

Level of consciousness Glasgow

Coma Scale
Orientation to person, time, place
Cognitive ability
Reflexes
Vital signs: All within normal limits,
including the blood pressure reading
which is considered a high normal.
(Potter and Perry, 525)

Sensory deficits
Altered sleep

Evidence of pain acute or chronic

Description of pain experience
location, source, onset, duration

FINDINGS
25 respirations/minute and shallow.
Fine Crepitus
SaO2 86%, increased to 92% with 2
litres of O2.
88bpm.(Within normal limit.)
Clear S1 and S2, however with an
irregular rhythm.
130/94 WNL(Potter & Perry, 525)
N/A
Yes SOB
Lab Tests W.N.L.s

12. (Potter and Perry, 558).

Not oriented to time and place.

Temp 37.4C, Pulse 88, BP

130/94,SaO2 92% with 2Litres of
O2.
Mrs. Walesa needed lots of
encouragement to get out of bed
this morning and wishes to back to
sleep after breakfast.
Mrs. Walesa has chronic pain in her
left knee most likely from her
osteoarthritis, however today she
says it is worse than normal. She
moans my knee, my knee, and is
rocking backward and forward. The
knee is warm to touch and red over
the patella.

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SYSTEM
Gastrointestinal
System

Urinary System

Musculoskeletal
System

ASSESSMENT

Eating Patterns
Food intake
Appetite
Weight
Height
Body Mass Index(BMI)
Bowel sounds
Pain
Altered bowel patterns
Consistency of stool
Fluid intake & output 24 hours

Mrs. Walesa only eats 75% of her

meals and reluctantly accepts her
diabetic snacks.
Soft CDA diet at 18:00

Normally passes medium, brown

soft stool daily.

Urine amount, colour, transparency,

odour
Frequency, urgency, effort
Pain, burning
Incontinence

Foul smelling, concentratedappearing urine.

Posture, gait, coordination

Client needs walker to coordinate

her movements, and is a one person
transfer from bed to chair.
Uses pillow on her wheelchair and
uses a pressure reduction mattress
to aid with pressure sores from
body alignment.
Left knee flexion is 100 degrees
compared to right knee flexion of
120 degrees. The left extension is
110 degrees compared to the right
extension of 120 degrees.
Poor, client cannot walk on left leg.
Redness, heat and pain on left knee.

Body alignment

Range of motion

Muscle strength
Evidence of injury/trauma
Integumentary
System

FINDINGS

Condition of skin, scalp, nails, mucous

membranes
Tissue turgor
Lesions
Perspiration
Sensitivity to temperature change
Body temperature
Presence of sensation

Yes, 5cm. blue line on incontinent

product.

Ischial tuberosity, the size of a

loonie which disappears after client
rests in bed for two to three hours.
37.4(W.N.L.s)

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SYSTEM

ASSESSMENT

FINDINGS

Structural change in skeleton, adipose

tissue, integument
Functional change in:
Vital signs
Neuromuscular system
Renal function
Emotions
Sexual development
Menstruation
Pregnancy changes
Labour and delivery
Lab test findings

Blood glucose is at 1.8mmol/dl.

Senses

Degree of function and effects of

altered sensation in each of the senses:
vision, hearing, touch, smell, taste

Not oriented to time and place.

Environmental
Factors that Affect
Function of Systems

Self-concept

She is a mother, was a wife and is a

survivor of a concentration camp.
She is resilient.
She is emotionally supported by
two of her kids who live nearby
however it is limited supported
because they are quite busy with
their own lives.

Endocrine System

Support systems
Roles
Developmental changes
Lifestyle factors
Family background, strengths, coping
abilities
Health status
Pathophysiology (disease)
Medical diagnoses
Related medical treatment
Medications

Determinants of health

All within normal limits

Irritable

She presently struggles with left

sided heart failure, type 2 diabetes
and osteoarthritis.

She takes Furosemide, Metformin,

Metaprolol, Docusate Sodium,
Prevacid and Acetylsalicylic Acid.
The clients health has been strongly
affected by many determinants of
health such as her age, her poor
eating habits, her unhealthy early
child development and her gender.

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Nursing Assessment Form

Client Name: Mrs. Walesa

Medical Diagnosis: Type 2 Diabetes, Left-Sided Heart

Failure and Osteoarthritis.

Client Perception of Health Needs: Pain relief related to redness and swelling in left knee and
disoriented to time and place.
Client Goals for Health: Client will eat 100% of the meals she eats each day related to risk for
nutritional deficits related to her diabetes as is evident by her low blood sugar measurement of
1.8mmol/dl.

Allergies
(food,
medication,
environmental)

N/A

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Furosemide (Lasix):40mg. PO bid given at breakfast and lunch. Safe Dose

Metformin (Glucophage): 500mg. PO with each meal.
Safe Dose? No, it should only be 500mg PO, twice daily, not three times a
day unless the client is taking more than 2000mg. per day.
Metaprolol (Lopressor): 12.5 mg. PO daily at breakfast. Safe Dose
Medications
Docusate Sodium (Colace): 200mg PO bid daily, given at breakfast and
supper. Safe Dose:Yes
Lansoprazole (Prevacid): 30 mg. PO ac given in the morning. Safe Dose: Yes
Acetylsalicylic Acid (ASA): 81mg PO daily, given at breakfast. Safe
Dose:Yes

Client only eats 75% of meals and reluctantly, takes the in-between
diabetic snacks that are given to her between meals. This could adversely
affect how the Glucophage acts on the body as Daviss Drug Guide Tells us
Dietary
considerations

that the patient need to follow their prescribed diet if recommended (p.832).

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Pain rating
Vital Signs
Much worse
All within

T 37.4

P 88

R25

BP130/94

O2 sats 92%

Today.

normal limits!

HEALTH ASSESSMENT DATA

Physiological Variable
General Appearance/Mental State: Not

Cardiovascular System: Left Sided heart

oriented to time and place, fatigued.

failure. B.P. 130/94

Respiratory System: Respirations shallow at

Gastrointestinal System: Soft CDA diet at

25. Fine Crepitus heard in Lung Sounds.

18:00. Usually passes medioum brown stool

daily.

Urinary System: Incontinent of urine, 5 cm. of

Sensory Systems: Not oriented to time and

blue line on incontinent pad. Foul smelling

place.

concentrated urine.
Nervous System: Not oriented to time and

Integumentary System: Ischial tuberosity

place, irritable.

causes loonie sized reddened area that

disappears after Mrs. Walesa lies down for two
to three hours.

Musculoskeletal System: Shaky, left knee

warm, red sore and causing her to moan my
knee, my knee. Cannot weight bear on left
leg today. Requires a one person transfer from
bed to wheelchair,

Reproductive System: N/A

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HEALTH ASSESSMENT DATA

Endocrine System: Type 2 diabetic. Takes
Metaformin with each meal.
Spiritual Variable (Environment): Polish

Developmental Variable (Environment):

Roman Catholic, bible at bedside.

She was admitted to long term care after six

months because of failure to thrive. She now
has access to many health professionals such
as nurses, physiotherapists, occupational
therapists, and recreational therapists to help
improve her health

Sociological Variable (Environment): She

Psychological Variable (Environment): Was

had eight children, home-steaded in Alberta

born in Warsaw, Poland and spent 5 years in a

with her husband, was active on the farm and

prisoner of war concentration camp. She is

taught her eight kids how to read and write.

now widowed, her husband died 8 years ago.

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HEALTH ASSESSMENT DATA

Determinants of health impacting clients health (Environment)
Socially: She participates in recreational activities, receives letters from her family, and
occasionally sees one of her sons who lives nearby or her daughter.
Individual Health Practices and Coping: Client participates in some recreational activities
however she eats only 75% of her meals and does not like having small snacks between meals;
important aspects for a diabetic.
Gender: Women according to Potter and Perry are more likely to suffer from chronic
hildiseases such as arthritis(p.9), which is indicative as Mrs. Walesa has osteoarthritis which
dramatically influences her health.
Healthy Childhood Devlopment: The Client was raised in a concentration camp and healthy
foods choices may not have been an option. Furthermore poor childhood development as
indicated by Potter and Perry has been linked to heart disease and type 2 diabetes( p.9).
Interdisciplinary Team Members: Client has access to nurses, physiotherapists, occupational
therapists and recreational therapists.
Health Priorities: Manage Diabetes, monitor patients signs and symptoms associated with her
heart failure, attend to any significant changes in the clients health immediately and manage
the clients pain associated with her osteoarthritis.
Client Strengths
Mrs. Walesa is resilient to hardships and has managed to be strong while living in a
concentration camp, and while raising and teaching eight kids.
Another strength of hers is that she realizes the need to exercise and is motivated to walk from
the nursing station to the dining room with her walker every day at lunch time.

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Nursing Diagnosis

Planning

Interventions

#1
Risk for injury

Client Goals: Client will

1. List Interventions (a)

1. A

related to low blood

eat 100% of her meals at

The Nurse will withhold

sugars as evidenced

each sitting and will

the Glucophage, until

by a low blood

ensure she eats all of her

further instructions

re

glucose reading of

diabetic snacks between

from the Dr.(b) The

1.8mmol/Litres, an

meals, which will be

client will vocalize the

incorrect dose of

reflected in a normal

ill effects of both

Glucophage and the

blood glucose reading of

hypoglycemia and

clients disoriented

between 4-

hyperglycemia on her

view of time and

6mmol/Litre(Potter &

diabetic health.

place.

Perry, 1073).
Expected Outcome: If

b
2. C

fi

th
2 Rationale for

goals are met the client

Interventions:(a)The

will be oriented to place

Glucophage Dose is to be

and time, and will be

administered as 500mg PO

more steady on her feet.

with each meal however this

may not be a safe as Daviss
Drug Guide indicates
Glucophage should only be
given as 500mg PO, twice
daily, not three times a
day(831,832). Consequently
this may be contributing to
the clients low blood glucose.
(b)By identifying the ill effects
associated with her Diabetes,
Mrs. Walema will be more

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Nursing Diagnosis
#2

Planning
1. Client Goals: The

Interventions
1. List Interventions(a)

1. Achieve

Acute pain related

client will immediately

The nurse will perform a

Outcom

to redness and

alert the nurse when

pain assessment on Mrs.

longer e

swelling of the left

experiencing a pain

Walema using the

knee as evidenced

level of 4,on the

assessment criteria for

by the clients

numeric pain scale

pain such as its onset,

statement my knee

(Potter & Perry, 1023).

duration, location,

hurts, my knee

This will enable the

quality, and what makes

hurts.

nurse to treat the

the pain worse or

clients pain before it

better(Potter & Perry,

gets worse.

1021,1022).(b)The nurse

2. Expected

will also assess how Mrs.

Outcomes: The

Walemas pain is

client will experience

affecting how she

more comfort, and

manages her activities

will only feel pain at

of daily living.

a rating of four or
less.

as is ind

no longe
not red

report a

a rating

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2. Rationale for
Interventions(a) According to
Potter and Perry pain
assessments direct the nurse
to choose the right course of
action to relieve the clients
pain(1020). This action also
facilitates getting a Doctors
order for a pain medication.(b)
The nurse needs to know if the
patient needs help with
dressing or exercising, so as he
or she can work with the
patient to determine when to
rest and when to exercise to
better manage her pain (Potter
& Perry, 1023).

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Nursing

Planning

Interventions

Evaluation

Diagnosis #
3

Client Goals:

2. List

3. Achievement of

Impaired

The client

Interventions

Expected

urinary

will have

(a) The nurse

Outcomes: Clients

elimination

transparent

will take a

urine is now straw

related to

to straw

culture and

coloured, with no

foul smelling

coloured

sensitivity

odor and the goal

urine as

urine, with

sample from the

evidenced by

no odor in a

client.(b)The

72 hour

nurse will also

and findings:
Mrs.Walesa

promote intake

increased her fluid

of non-

intake of non-

caffeinated

caffeinated

beverages to

beverages and her

Mrs. Walesa.

Doctor( with

the
appearance
of
concentrated
urine and
Mrs.
Walesas
confusion
over time
and place.

period.
Expected
Outcomes:
If the above
client goals
are met the
clients
confusion
over time
and place
will be
lessened

3. Rationale for

has been met.

4. Client Responses

evidence of a

Interventions:

urinary tract

(a)To notify the

infection then

Doctor of any

ordered an

significant

antibiotic which

abnormalities

helped clear up her

(Potter and

infection.

Perry, 1111). (b)

Urinary tract
infection can be
prevented
through

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Summary
The benefits of utilizing the nursing process, to conclude, are apparent when one
remembers that using this system ensures every nursing action is thoroughly evaluated (Potter
and Perry, 65). Furthermore the nursing process, encourages not only the nurse but the patient to
critically think of how they can help each other to meet a client-centered goal in order to better
their health. In addition when carried over to the patients direct care or care plan, nurses must
use solid evidence to effectively care for their client. Consequently the process is beneficial
because it involves a consistent routine that strives to address every issue related to optimum
care of the client.

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References

American Psychological Association (2010). Publication Manual of the American Psychological

Association. (6th ed.). Washington, D.C. Published by the American Psychological Association.

Lippincott,Williams & Wilkins. (2010). Handbook of Signs and Symptoms. (4th ed.)(p.155)
Ambler, PA. Published by Lippincott, Williams & Wilkins.

Potter, P. A. & Perry, A.G. (2010) .Chapter 21: Client Education. Ross- Kerr J.C., Wood, M.J.
(4th ed.) Canadian Fundamentals of Nursing (pp.9,65,297 525,528,
1020,1021,1022,1023,1073,1111, 1116 ). Toronto, ON. Mosby Elsevier.

Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2013). Daviss Drug Guide for Nurses. (13 th ed.)
(p. 832). Philadelphia, PA.F.A. Davis Company.

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Nursing Care Plan

Meggan Nanton
NorQuest College
NPRT 2102
Acute Care Clinical Practicum
Instructor: Rhonda Meredith
June 03, 2014

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