Care Plan for Complex Patient: Plan of Care and Individual Written Report

This report contains an explanation of the A-G assessment of a complex patient's physical conditions, identification of health abnormalities, and nursing interventions.

Running head: CARE PLAN
ASSESSMENT TASK 1: Complex patient: plan of care and individual written report
Name of the Student
Name of the University
Author note

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Executive summary
A patient had been admitted to the medical ward after observing symptoms of hyponatraemia
and confusion. She had a medical history of diabetes mellitus and hypertension. This report
contains an explanation of the A-G assessment of her physical conditions, followed by
identification of six major health abnormalities, their characteristics, and the expected
outcomes, after implementing necessary nursing interventions. The report also provided a
detailed rationale for two priority nursing problems, based on quality evidences.

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Table of Contents
Introduction................................................................................................................................3
Background................................................................................................................................3
Assessment.................................................................................................................................4
Underlying pathophysiology......................................................................................................6
Nursing outcomes.......................................................................................................................8
Rationale for intervention of two major problems.....................................................................8
Conclusion................................................................................................................................10
References................................................................................................................................11
Appendix..................................................................................................................................15

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Introduction
Care plans are responsible for providing directions, related to individualised care for
patients and is typically based on the distinct diagnosis of the patient, and the associated
needs and preferences (Tabloski 2014). While the needs of the patients are attended to, the
nurses have the duty of passing on updated plans to other staff members at the time of
handover and shift changes, in order to ensure continuity of care. Another basis purpose of
nursing care plan can be correlated with documentation, whereby they precisely outline the
observations to that must be made, the nursing actions required to be executed, and the
directions that must be shared with the client and/or family members (Tanner 2006). In other
words, care plans act as guidelines for assigning healthcare staff to each patient and also
serve as a framework for medical reimbursement. This report will elaborate on a care plan for
a patient X (pseudonym) who has been suffering from hyponatraemia. The report will assist
in critical thinking and implementation of nursing process for solving problems that are
encountered while treating the patient.
Background
The patient X is a septuagenarian and had been admitted to the healthcare facility
three days earlier, after being referred to the centre by her general physician. The patient had
been identified to be a risk of fall and also had presenting complaints of confusion, which in
turn was accredited to the presence of hyponatraemia. Following her admission to the
hospital, 0.9% sodium chloride was intravenously administered that showed significant
improvements in the patient. However, on monitoring the patient it was found that she started
reporting symptoms of persistent confusion since the last hour, thus demonstrating
ineffectiveness of the administered intervention. A review at her past medical history
suggests that she had been diagnosed with type 2 diabetes mellitus and hypertension several

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years ago. In addition, she was currently under the medication of 1g metformin drug, thrice a
day. Although she had also been prescribed once daily administration of
2.5mgbendroflumethazide, it was currently withheld from her treatment. She did not have
any past history of allergic or hypersensitive reaction. An assessment of her social
circumstances suggests that she lives along and had lost her spouse 10 years ago. She had two
daughters of whom one lives in close proximity to the patient, while the other resides in the
UK.
Assessment
Taking into consideration the fact that all patients are admitted to hospitals with the
aim of improving their health and preventing any kind of deterioration in the health status,
conducting a thorough physical assessment of the patients acts imperative in delivering
efficient and prompt treatment. The A-G assessment approach specifically was conducted in
X, in the form of a quick bedside assessment of her deteriorating health condition. This
assessment served important in providing cues for early management of the patient condition
and also helped in establishing an order of priority, in relation to the treatment modalities.
The assessment involves conducting a physical evaluation of several parameters namely, (i)
airway, (ii) breathing, (iii) circulation, (iv) disability, (v) exposure, (vi) fluids, and (vii)
glucose.
An analysis suggested that the airway was patent and X could talk in complete
sentences, thus providing evidence for the presence of clear and open airways, without any
major obstruction. Thus, it suggested that if required, oxygen could be administered without
any surgical means. Thus, there were no signs or symptoms of haematoma or airway
obstruction. Breathing is generally assessed by noticing the chest wall movement and
measuring the respiratory rate (Gizzi et al. 2015). While checking for signs of breathing, X
reported an increased respiratory rate (RR=25), normal oxygen saturation levels, and mild

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elevation in work of breathing. According to El Ayadi et al. (2016) most medical
emergencies take into consideration the presence of hypovolaemia as the primary reason of
shock, unless otherwise proven. Therefore, circulation was assessed to identify presence of
signs and symptoms of cardiac cause (if any). In addition, presence of breathing difficulties
also significantly contributes to a deteriorated circulatory state. The patient’s heart rate was
quite high (135 beats/min), thus indicating presence of tachycardia (Sapp et al. 2016). In
addition, she reported hypotension (BP 98/60) and increased capillary refill time (CRT=4s)
(Kuipers et al. 2016). High response in Glasgow coma scale demonstrated that the patient
was alert. However, signs of spatial and temporal confusion persisted. An assessment of
exposure indicated presence of an inflammation in the inferior vena cava, thus suggestion
probable obstruction of the blood vessel (Kraft et al. 2014).
Although there was positive fluid balance, the patient manifested signs and symptoms
of poor oral intake. According to Cardoso et al. (2014) food refusal is a common sign of older
patients, which in turn increases risks of malnutrition and renal failure among the elderly.
Increased body temperature was another major sign, which can be accredited to the
inflammation. Further complications were also associated with oliguria or urine output that
was considerably less than the normal values of 800-2000 ml/24hours (150ml) (Cheah et al.
2017). X was also assessed for her blood glucose levels that were found to be quite high than
the normal range of 5.6 mmol/L (BGL= 15mmol/L). Laboratory investigations were also
conducted in the patient and suggested abnormal increase in the white cell count (18.3 vs 4.0-
11.0 normal range). In addition, the number of platelet was 367, which in turn was
significantly less than the normal platelet count of 150,000-450,000. No abnormalities were
observed upon conduction of a chest X-ray. However, abnormal results were found in the
values of arterial blood gas, in relation to oxygen partial pressure, carbon dioxide partial

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pressure, pH, oxygen saturation, and bicarbonate, thereby indicating presence of some
metabolic, or renal disease.
Therefore, some of the major nursing orientated problems that require immediate
attention and treatment are as follows:
1. Increased heart rate/tachycardia
2. Increased respiratory rate/tachypnoea
3. Reduced blood pressure
4. Dehydration
5. Oliguria
6. Increase in white blood cell count
Thus, a thorough analysis of the health assessment data facilitated identification of the
problem focused and risk diagnosis that are cited below:
 Dehydration and reduced intake as evidenced by low blood pressure, tachycardia,
reduced urine output, and hypotension (actual problem)
 Risk for infection due to compromised host defence mechanism as evidenced by high
count of white blood cells (potential problem).
Underlying pathophysiology
An analysis of the patient assessment reports suggest that X demonstrates signs and
symptoms of poor oral intake that can significantly contribute to the onset of dehydration.
This physiological condition generally occurs under circumstances that are marked by a
decrease in the amount of total body water, which in turn is concomitant with metabolic
process disruption. The negative fluid balance that resulted in dehydration in the patient
occurred due to decreased oral intake and/or fluid shift (El-Sharkawy et al. 2014). The
reduction in the amount of total body water resulted in a decrease in the extracellular and

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intracellular fluid volumes. In addition, dehydration can also be categorised on the basis of
severity and osmolarity. There is mounting evidence for the fact that serum sodium acts as a
prominent marker of osmolarity (Morley 2015). Dehydration can be hypernatremic,
hyponatremic, or isonatremic. Upon analysing the laboratory reports it was found that the
patient was suffering from isonatremic dehydration. Thus, the condition occurred when the
loss of fluid from the body was similar to the concentration of sodium present in the
bloodstream. The condition has been identified as a major health priority since severe
dehydration might result in the onset of intractable seizures. Furthermore, rapid improvement
of enduring hyponatremia (>2 mEq/L/h) has also been allied with central pontine
myelinolysis (Alleman 2014). Owing to the fact that X had been admitted due to
hyponatraemia, prompt care plan must be initiated, in order to prevent deterioration of health
status. Furthermore, reduced food intake in the patient will also create an impact on her
overall health and might result in malnutrition. Lack of adequate nutrients in the body will
eventually prevent repair and growth of body tissues and also has the potential for creating
several problems in the patient namely, unintentional loss of body weight, fatigue and
tiredness, depression, memory deficits, and weakened immune system.
The second problem identified is the risk of potential infection due to the presence of
a compromised host defence mechanism. Infection typically occurs due to invasion of the
cells and tissues of the body by pathogens that are responsible for the onset and progress of a
disease. Taking into consideration the fact that white blood cells have the property of fighting
off infection, an increase in their count suggests that the immune system is functioning to
prevent the attack of pathogens (Parham 2014). Infections generally begin upon successful
entry of an organism in the body. Time and again it has been found that people, who are sick,
malnourished, diabetic, or weak, report an increased susceptibility of suffering from
persistent or chronic infections (Loeffen et al. 2015). This can be accredited to the presence

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of a suppressed immune system that becomes vulnerable to opportunistic infections. A
compromised immune system suggests that the patient’s boy might have had a diminished
immunity level that made her more susceptible to infection. One major symptom of a
compromised immune system was inflammation in the inferior vena cava, thus suggesting
possible inferior vena cava syndrome (Spentzouris et al. 2014). Hence, there is a need to
immediately increase immunogenicity in X, with the aim of provoking a cell-mediated
immune response in her body that will help in fighting off germs.
Nursing outcomes
The outcomes for the aforementioned problems are given in appendix.
Rationale for intervention of two major problems
There is mounting evidence for the efficacy of oral fluid replacement, in relation to
treatment of mild fluid deficit, and it has also been identified to be a cost-effective
intervention for replacement treatments among patients suffer from dehydration (Voldby &
Brandstrup 2016). Elderly patients frequently report a decreased feeling of thirst and are
required to be given ongoing recalls and reminders for consuming adequate amount of fluids.
Fluid replacement can also be facilitated by offering selection in fluid sources, apart from
administration of oral rehydration solution. This solution involves water consumption, along
with specific amount of sugar and salt, specifically potassium and sodium, with the aim of
replenishing water and sodium loss. Parenteral fluid replacement will also help in treating
hypovolemic complications through the intravenous administration of colloid solutions,
crystalline solutions and or blood products (Bihari et al. 2016). This calls for the need of
determining the amount and type of fluid that will be replaced, and variations will also be
observed in the infusion rate, depending on the clinical status of the patient. Adding fluid rich
food such as, oranges, watermelon, strawberries, cantaloupe, and peaches in the diet have

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also proved effective in increasing fluid balance among patients (Tulipani et al. 2014). Fluid
deficit has also been associated with the presence of a sticky or dry mouth (Mohammed
2014). Giving nursing attention to mouth care will promote an interest of the patient in
sufficient fluid intake, and will subsequently reduce discomfort caused due to presence of dry
mucous membrane. The patient will also be provided education on the importance of drinking
fluid, which will effectively help in management and prevention of dehydration. However,
emergency care might be needed in conditions when the patient progresses to hypovolemic
shock.
Time and again it has been proved that showing adherence to aseptic techniques in
nursing care practices such as, the use of alcohol for sterilizing skin, instruments, and surgical
asepsis, in addition to the usage of sterile gloves, masks, gowns, and other personal protective
equipment (PPE) help in preventing the transmission of germs from an infected person to a
healthy person (Megeus et al. 2015). Following the five steps of hand hygiene with strict
compliance will also prove effective in removing microorganisms from the hands of
healthcare professionals, thereby lowering risks of pathogen transmission (Chassin, Mayer &
Nether 2015). Usage of antiseptic, soap and water for washing hands, followed by using
alcohol based hand rubs has been identified as the mainstay procedure for nosocomial
infection control (Kundrapu et al. 2014). Encouraging the patients to intake adequate amount
of fluid will also promote dilution of urine, thus leading to frequent bladder emptying. This
will thereby lower urine stasis and risk for associated bladder infection (Hopper et al. 2014).
Recognizing the risk factors for infection will also help in preventing for the compromise of
the immune system. Necessary steps will also be taken to maintain proper skin care and oral
hygiene, in order to ensure that the first line of defence starts functioning properly, thereby
preventing further entry of pathogen.

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Conclusion
To conclude, one major objective of a care plan process is associated with
organisation and communication of necessary actions of the nursing staff, adorned with the
responsibility of providing healthcare services to the patients. The case scenario discussed
above identified six major nursing problems, of which the two most important ones were risk
of infection due to compromised immune system and presence of dehydration. This was
followed by discussion on interventions for management of the problems, based on
evidences.

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References
Alleman, A.M., 2014, April, ‘Osmotic demyelination syndrome: central pontine myelinolysis
and extrapontine myelinolysis’, In Seminars in Ultrasound, CT and MRI (vol. 35, no.
2, pp. 153-159). WB Saunders.
Bihari, S., Watts, N.R., Seppelt, I., Thompson, K., Myburgh, A., Prakash, S. & Bersten, A.,
2016, ‘Maintenance fluid practices in intensive care units in Australia and New
Zealand’, Critical Care and Resuscitation, vol.18, no.2, p.89.
Cardoso, B.R., Bandeira, V.S., Jacob-Filho, W. & Cozzolino, S.M.F., 2014, ‘Selenium status
in elderly: relation to cognitive decline’, Journal of Trace Elements in Medicine and
Biology, vol.2, no.4, pp.422-426.
Chassin, M.R., Mayer, C. & Nether, K., 2015, ‘Improving hand hygiene at eight hospitals in
the United States by targeting specific causes of noncompliance’, The Joint
Commission Journal on Quality and Patient Safety, vol.41, no.1, pp.4-12.
Cheah, I.K., Tang, R.M., Yew, T.S., Lim, K.H. & Halliwell, B., 2017, ‘Administration of
pure ergothioneine to healthy human subjects: Uptake, metabolism, and effects on
biomarkers of oxidative damage and inflammation’, Antioxidants & redox
signaling, vol.26, no.5, pp.193-206.
El Ayadi, A.M., Nathan, H.L., Seed, P.T., Butrick, E.A., Hezelgrave, N.L., Shennan, A.H. &
Miller, S., 2016, ‘Vital sign prediction of adverse maternal outcomes in women with
hypovolemic shock: the role of shock index’, PLoS One, vol.11, no.2, p.e0148729.
El-Sharkawy, A.M., Sahota, O., Maughan, R.J. & Lobo, D.N., 2014, ‘The pathophysiology of
fluid and electrolyte balance in the older adult surgical patient’, Clinical
Nutrition, vol.33, no.1, pp.6-13.

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Gizzi, C., Klifa, R., Pattumelli, M.G., Massenzi, L., Taveira, M., Shankar-Aguilera, S. & De
Luca, D., 2015, ‘Continuous positive airway pressure and the burden of care for
transient tachypnea of the neonate: retrospective cohort study’, American journal of
perinatology, vol.3, no.10, pp.939-943.
Hopper, S.M., McCarthy, M., Tancharoen, C., Lee, K.J., Davidson, A. & Babl, F.E., 2014,
‘Topical lidocaine to improve oral intake in children with painful infectious mouth
ulcers: a blinded, randomized, placebo-controlled trial’, Annals of emergency
medicine, vol.63, no.3, pp.292-299.
Kraft, C., Schuettfort, G., Weil, Y., Tirneci, V., Kasper, A., Haberichter, B., Schwonberg, J.,
Schindewolf, M., Lindhoff-Last, E. & Linnemann, B., 2014, ‘Thrombosis of the
inferior vena cava and malignant disease’, Thrombosis research, vol.134, no.3,
pp.668-673.
Kuipers, J., Oosterhuis, J.K., Krijnen, W.P., Dasselaar, J.J., Gaillard, C.A., Westerhuis, R. &
Franssen, C.F., 2016, ‘Prevalence of intradialytic hypotension, clinical symptoms and
nursing interventions-a three-months, prospective study of 3818 haemodialysis
sessions’, BMC nephrology, vol.17, no.1, p.21.
Kundrapu, S., Sunkesula, V., Jury, I., Deshpande, A. & Donskey, C.J., 2014, ‘A randomized
trial of soap and water hand wash versus alcohol hand rub for removal of Clostridium
difficile spores from hands of patients’, Infection Control & Hospital
Epidemiology, vol.35, no.2, pp.204-206.
Loeffen, E.A., Brinksma, A., Miedema, K.G., De Bock, G.H. & Tissing, W.J., 2015, ‘Clinical
implications of malnutrition in childhood cancer patients—infections and mortality’,
Supportive Care in Cancer, vol.23, no.1, pp.143-150.

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Megeus, V., Nilsson, K., Karlsson, J., Eriksson, B.I. & Andersson, A.E., 2015, ‘Hand
hygiene and aseptic techniques during routine anesthetic care-observations in the
operating room’, Antimicrobial Resistance and Infection Control, vol., no.1, p.5.
Mohammed, A.A., 2014, ‘Update knowledge of dry mouth-A guideline for dentists’, African
health sciences, vol.14, no.3, pp.736-742.
Morley, J.E., 2015, ‘Dehydration, Hypernatremia, and Hyponatremia’, Clinics in geriatric
medicine, vol.31, no.3, pp.389-399.
Parham, P., 2014, The immune system, Garland Science.
Sapp, J.L., Wells, G.A., Parkash, R., Stevenson, W.G., Blier, L., Sarrazin, J.F., Thibault, B.,
Rivard, L., Gula, L., Leong-Sit, P. & Essebag, V., 2016, ‘Ventricular tachycardia
ablation versus escalation of antiarrhythmic drugs’, New England Journal of
Medicine, vol.375, no.2, pp.111-121.
Spentzouris, G., Zandian, A., Cesmebasi, A., Kinsella, C.R., Muhleman, M., Mirzayan, N.,
Shirak, M., Tubbs, R.S., Shaffer, K. & Loukas, M., 2014, ‘The clinical anatomy of the
inferior vena cava: a review of common congenital anomalies and considerations for
clinicians’, Clinical anatomy, vol.27, no.8, pp.1234-1243.
Tabloski, P.A., 2014, Gerontological nursing, New York, NY, USA: Pearson.
Tanner, C.A., 2006, ‘Thinking like a nurse: A research-based model of clinical judgment in
nursing’, Journal of nursing education, vol.4, no.6.
Tulipani, S., Armeni, T., Giampieri, F., Alvarez-Suarez, J.M., Gonzalez-Paramás, A.M.,
Santos-Buelga, C., Busco, F., Principato, G., Bompadre, S., Quiles, J.L. & Mezzetti,
B., 2014, ‘Strawberry intake increases blood fluid, erythrocyte and mononuclear cell
defenses against oxidative challenge’, Food chemistry, vol. 156, pp.87-93.

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Voldby, A.W. & Brandstrup, B., 2016, ‘Fluid therapy in the perioperative setting—a clinical
review’, Journal of Intensive Care, vol.4, no.1, p.27.

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Appendix
Plan of care
Patient or nursing
oriented problem or
patient need
Patient assessment data Optimal patient outcome or goal
1. Dehydration and
reduce fluid
intake
 Low blood pressure
 Tachycardia
 Dry mucous
membrane
 Concentrated urine
 Reduced urine
output (lesser than
30ml/hr)
 Hypotension
 Sudden weight loss
 Tachycardia
 Thirst
 Mental state
alterations
 Patient will become
normovolemic
 Systolic blood pressure
will be greater than or near
90mmHg
 Heartbeat will restore to
60-100 beats/min
 Urine output will be higher
than 30 ml/hr
 Mucous membrane will
become moist
2. Risk of suffering from
infection
 High count of white
blood cells
 ICV inflammation
 Patient will be free of
infection as evidenced by
absence of any major signs

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 Pain
 Chills
 Weight loss
 Loss of appetite
 Fatigue
and symptoms and normal
vital signs
 Early infection recognition
for from effective
treatment
 Demonstration of stringent
hand washing techniques
3. Tachycardia increased
heart rate
 Heart rate 135 that is
greater than normal
levels of 60-100
beats/min
 Crackles
 Dyspnoea
 Reduced cardiac
output
 Restlessness and
anxiety
 Abnormal heart
sounds
 Hypotension
 Decreased urine
output
 Patient will manifest
sufficient cardiac output
by measuring pulse rate,
blood pressure, and heart
rhythm within normal
parameters
 Presence of strong
peripheral pulse
 Absence of any symptoms
of dyspnea, chest pain, or
syncope
 Exhibition of dry skin and
eupnea without any
pulmonary crackle
 Absence of any side
effects of medications that
are administered for

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achieving sufficient
cardiac output
4. Tachypnoea or
increased respiratory rate
 Respiratory rate 25
breaths/min, higher
than normal 12-
20breaths/min
 Decreased PO2
 Holding breath
 Increased
restlessness and
apprehensions
 Reduced lung
volume
 Dyspnoea
 Change in
respiratory depth
 Patient will be able to
maintain an adequate
breathing pattern, as
observed by relaxed
breathing and normal
depth
 Absence of dyspnoea
 Presence of respiratory
rate within the established
normal limits
 Returning of ABG level
to normal limits
 Verbal or behavioural
indication of the patient
about comfortable
breathing
 Ability to perform
diaphragmatic pursed lip
breathing
 Maximum lung expansion

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under sufficient ventilation
5. Hypotension or reduce
blood pressure
 Blood pressure
98/60 mmHg in
place of normal
120/80 mmHg
 Headache
 Fatigue
 Shortness of breath
 Irregular heartbeat
 Maintenance of blood
pressure within acceptable
individual ranges
 Demonstration of a stable
cardiac rhythm
 Participation in activities
that help in lowering stress
6. Oligouria or reduced
urine output
 Urine output of 150
ml in 8 hours in
place of 800-2000
ml in a day
 Restlessness
 Confusion
 Change in mental
status
 Tissue oedema
 Intake larger than
output
 Rectify and eliminate
reversible reasons for
kidney failure
 Restore electrolyte balance
in the body
 Presence of an adequate
urine output with normal
specific gravity
 Absence of oedema
 Stable body weight
Table 1- Nursing care plan