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NURSING CARE PLAN By: Reema H. Matar Adult 1

NURSING CARE PLAN By: Reema H. Matar Adult 1. Admission Data Base. Client : A.A.A Age : 66 years old Sex: Male Spoken language: Arabic Date of Admission : 12/4/2011 … Via : Emergency Department Source of Data : File, Patient, Family, and Physiotherapist

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NURSING CARE PLAN By: Reema H. Matar Adult 1

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  1. NURSING CARE PLANBy: Reema H. MatarAdult 1

  2. Admission Data Base • Client: A.A.A • Age: 66 years old • Sex: Male • Spoken language: Arabic • Date of Admission: 12/4/2011 … Via: Emergency Department • Source of Data: File, Patient, Family, and Physiotherapist • Condition on arrival: Wheelchair

  3. Reason for Hospitalization: Patient suffered of severe left side pain after falling on left leg • Confirmed Diagnosis: Femur neck fracture

  4. Dynamic Hip Screw!

  5. History • Past Medical History: Diabetes Mellitus (since 15 years ) Hypertension (since 15 years) Old stroke (13 years ago) • Past Surgical History: Cataract for both eyes – University Hospital Chest drainage • Family History: Key: : Male : Female : Patient : Dead : Household members : Married

  6. Health Maintenance – Perception Pattern Smoking: …. Yes (3-4 packs/day) Alcohol: … No Allergies: …. No Activity/Exercise Pattern Assesment (Subjective Data)

  7. Nutrition/Metabolic Pattern Diet: Regular Prescribed diet: Low Salt Dentures: upper and lower Elimination Pattern Used to complain of chronic constipation (going once per two weeks) but no longer complains due to Dalcolax medicine (laxative)

  8. Sleep/Rest Pattern: Usual number of hours/night (7-8) takes AM and PM naps After hospitalization the patient complains of not being able to sleep due to pain of left side. Cognitive/Conceptual Pattern: After doing cataract surgery for both eyes, the patient now sees well in both eyes

  9. Coping Stress/Self Perception Pattern: Major Concern: The patient does not like the hospital and is very upset regarding elimination in diaper. He says “I don’t like having to let the nurses change me”. Major Change: Cannot move due to prescribed immobilization Coping Mechanisms: Talks to neighbors and family Value – Belief Pattern: Muslim Role – Relationship Pattern: Retired, and lives with his 2 sons, wife, and daughter

  10. 1.General Survey: Level of Consciousness: Awake, alert, conscious Orientation: Aware of place, time, and persons Height: 168 cm Weight: 65 kg Temperature: 36.5 C 2. Nutritional – Metabolic Pattern: (A).SKIN: Color: tan - brown Symmetrical: Yes, bilateral Temperature: Warm Turgor: Elastic, mobile, return quickly Texture: Smooth Moisture: Dry Lesions: Yes, incision wound Edema: No Pruritus: No Tubes: No Physical Examination (Objective Data)

  11. (B) Oral Cavity: Lips: No lesions Gums: Pink, no masses or lesions Teeth: Upper and Lower dentures Tongue: Protrude in midline, no lesions Mucous membrane: mucosa and gingivae pink, no masses, no lesions (C) Neck: Symmetrical: Yes Thyroid: Not palpable, no bruits Carotid Pulse: Smooth rapid upstroke, slower down stroke, equal bilateral, +2 Jugular Venous Pressure: Present when supine, disappear at 45 degree position. Lymph Node Enlargement: No (D) Abdomen: Symmetrical: Yes Contour: Round, smooth no masses or lesions Umbilicus: Midline, inverted, no discoloration or inflammation Number of bowel sounds/minute: 10 Abnormal sounds: No Masses: No Organomegally: No Tenderness: No

  12. 2. Activity – Exercise Pattern: (A) Lung and Thorax: Respiration: 18 breath/minutes; relaxed, regular, silent Symmetrical Chest Movement: Yes Lung Expansion: Symmetric bilateral with no lags in expansion Breathing sounds: Bronchial (high pitched, loud amplitude: inspiration shorter than expiration) Bronchovesicular (moderate, mixed sound: inspiration equal to expiration) Vesicular (Low, soft, rusting sound: inspiration longer than expiration) Adventitious sounds: No (B) Cardiovascular: Blood Pressure: 120/70 mmHg Apical Pulse: 90 b/m short, gentle tapping, full bounding, no bruits Peripheral Pulses: All are present, +2, irregular, and equal bilateral Abnormal Hear Sounds: No (C) Musculoskeletal: Temperomandibular Joint: No crepitating, full ROM Neck Joint: full ROM, full resistance, non-tender Upper Extremities Joints: Right arm has full ROM, left arm cannot be moved on his own Lower Extremities Joints: Right leg has full ROM, left leg cannot be moved due to old stroke and femur neck fracture Spine: Straight, no masses, normal curvation, full ROM (bending and rotation)

  13. 4. Cognitive-Perceptual Pattern: (A) Eyes: PERRLA (B) Ears: Skin intact, no masses, no tenderness or discharge, hearing whisper bilateral (C) Nose: No deformity, nares patent, no discharge, not tender (D) Mental Status: Can calculate, think abstractly, and memory is good. (E) Neurological Status: Has intact cranial nerves, However due to old stroke the entire left side of body lacks sensory and motor function

  14. MEDICATION PROFILE

  15. Diagnostic Evaluation

  16. Nursing Care Plan

  17. Other Possible Diagnosis: • Activity intolerance related to trauma as evidenced by inability to perform activity of daily living • Ulteration in bowel movement (constipation) related to … as evidenced by … • Anxiety due to self-care deficit (elimination) related to prescribed activity restrictions • High risk for impaired skin integrity related to immobility

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