Nursing Care Plan

This document provides a nursing care plan for Mr McFarlane, including assessment, interventions, and expected outcomes. It covers areas such as promoting independence and providing support for personal care, protecting the integumentary system, preventing skin breakdown, and improving respiratory functioning. The document also discusses the importance of deep breathing exercises and provides strategies for managing Mr McFarlane's obesity and Type II diabetes. The multidisciplinary team that can assist with support and education is also mentioned.

Nursing Care Plan

Table of Contents
Question 1...................................................................................................................................3
Question 2...................................................................................................................................6
Question 3...................................................................................................................................8
Question 4.................................................................................................................................10
Question 5.................................................................................................................................11
Question 6.................................................................................................................................13
Question 7.................................................................................................................................14
Question 8.................................................................................................................................15
Clinical report documentation................................................................................................17
REFERENCES..............................................................................................................................18

Question 1
Referring to the information provided in Mr McFarlane’s case study, complete the nursing
admission form, on the template provided below, using appropriate medical terminology. Ensure
the documentation meet legal requirements.
NAME: Mr George McFarlane
ADDRESS: 23 Sunset drive, Homerville. 2300
GP: Dr Geoff Waterson
DATE:
AGE ON
ADMISSION: 53
GENDER: Male
ALLERGIES:
PREVIOUS
MEDICAL
HISTORY:
 Patient has Type ll Diabetes which needs close management
 COPD or Chronic Obstructive Airway disease
 Osteoarthritis in the Left Knee
 PVD or Peripheral vascular Disease
LIFESTYLE
PATTERNS:
The occupation of the patient: Long haul truck driver .
Alcohol or ETOH usage is extremely high due to consumption on a
regular basis, High tobacco consumption from smoking. The patient has
high intake of fast food.
ADL
ASSESSMENT:
DIET: 5
MOBILISATION: 3

HYGIENE: 8
ELIMINATION:10
ADMISSION
OBSERVATIONS:
T: 36.9, P: 99, R: 17, BP: 150/100, SpO2: 96%, GCS: 15, Pain score:
8/10
HEIGHT: 170cm WEIGHT:135 kg BMI: 46.7 kg/m2
 2/24 Vital signs
 2/24 Neurological observations
 2/24 neurovascular observations on L) leg
 Non weight bearing on L) Leg
Skin assessment
(Including
Waterlow/ Braden
score)
Special risks
 Neurological deficit: 5 (Type II Diabetes)
 Tissue malnutrition: Smoker: 5 (PVD) + 1 (smoking)
 Major surgery/trauma: 0
 Build/weight for height: 2, Morbidly obese
 Sex and Age: 1, 2 (Male, 53)
 Mobility: 2 (Apathetic)
 Continence: 0 (Complete)
 Visual risk areas/Skin type: 1 (Oedematous)
 Malnutrition screening tool: 0 (no weight loss)
Total score : 19 (High Risk)

Falls risk
assessment
Recent falls: 5
Medications: 6
Psychological:3
Cognitive status: 1
Total score: 15 (high risk)
NURSING
NOTES:
Reason for presentation to hospital:
Patient sustained a fall at home after feeling dizzy and blacking out.
Patient is experiencing severe pain in his left knee, unable to bear any
weight on his left leg and is unsteady. Patient is feeling dizzy and is
unable to stand in an upright position.
Admission Plan:
Patient has been admitted, the vital signs have been assessed, a further
investigation on the osteoarthritis of the L) knee is required. Patient has
been transferred to the Med/surgical ward at 0730 hrs. Referrals for
dietician, physiotherapist, diabetic educator, endocrinologist and social
worker have to arranged via electronic medical record.
Name: ___________________ Signature: _______________ Date: ____________

Question 2
As a new admission to your ward, you need to plan appropriate care for Mr McFarlane, based on
the information received in the case study. Use the template below to outline the anticipated care
for Mr McFarlane taking into account your EN Scope of Practice. To complete this question
you need to:
 Specify four (4) nursing diagnoses or risk factors associated with the client’s current
health presentations. (Consider BMI, Manual Handling, non-weight bearing on Left leg
due to osteoarthritis, current vital signs, pain score, poor diet/ take away foods, Type ll
Diabetes requiring close monitoring, smoker, SOB on excursion, COPD, PVD, recently
experiencing dizziness on standing upright.)
 Record at least two (2) nursing interventions that could be applied for each diagnosis,
these interventions must be in lines with current best practice standards.
 Specify at least one (1) member of the multi – disciplinary team that may be able to
support your suggested interventions.
Nursing
diagnosis
Planning - (Nursing intervention) Multidiscipli
nary member
to provide
support
Expected Outcome
Osteoarthritis
 Assistive devices like
Canes and ambulatory
devices.
 Analgesic to be given for
pain management for
effective exercises in
weight loss program.
 Physical therapy (Rohr &
Alvim, 2016)
Practice
Nurses
Recovery of the
cartilage tissue and pain
relief within 6 months
by 50%
Type II
Diabetes
 Educate about home
glucose monitoring after
reviewing factors in
glucose instability.
General
practitioner
and health
educator
To normalise blood
glucose levels within
moderate range and
monthly monitoring

 Checking viability of
insulin and reviewing type
of insulin used.
(AM & San Martín
Rodríguez, 2020).
Chronic
obstructive
pulmonary
disease
(COPD)
 Monitor and assess breath
sounds, respiration and
sounds like tachypnea,
wheezes, crackles and note
the expiratory and
inspiratory ratio.
 Assisting the patient to
take a comfortable position
and head midline to be
positioned with flexion.
 Also encourage patient to
do breathing exercises.
Allied health
professionals
To maintain patency in
the airway with a clear
breathing sound in a
period of 5 months
(Hansen & et.al., 2017).
Peripheral
Vascular
disease (PVD)
 Administering prescribed
medications to alleviate
symptoms of pain.
 Assessment of vital signs
of the patient after 30-40
minutes of medication.
 Administering analgesics,
anticoagulants and
ensuring enough
hydration.
 Avoiding elevation of legs
above the level of heart.
Community
health nurses
To minimize the pain
score from 8 to 3 within
6 months, stabilizing
vitals, decreasing
restlessness (Lopes-
Costa & Amato-
Vealey, 2016).

Question 3
Mr. McFarlane is not able to weight bear or mobilise very well. He is mostly restricted to bed
due the pain in his left knee. The NCP indicates that Mr McFarlane is for a sponge in bed and
requires full bed sheet change. He currently has a pain score of 7/10.
How could you encourage independence for Mr McFarlane and ensure he is able to actively
assist with his own personal care?
In your answer consider areas of:
 Privacy and dignity considerations
 Gaining informed consent and appropriate language.
 Pain management prior to initiating care
 oral hygiene and grooming
Safety considerations for Mr McFarlane due to his obesity and BMI of 47, consider manual
handling requirements.
Response:

Self -management and self-care support consists of a comprehensive way to assist the patient
and not only supply patients with information. A committed patient-centred care has to be
devised for Mr.McFarlane to enable him to manage health on a regular basis and take active
role in his healthcare. A compassionate and complete care has to be made in which whole team
has to be plan, carry out and follow up on patient visits. Planning the patient visits has to focus
upon care management and prevention instead of acute or critical care. Mr.McFarlane has to be
involved in the goal setting and his perspectives, needs and requirements have to be assessed.
According to his understanding levels and education, provision of customised skill and training
have to be used while taking care of the culture, values, beliefs and demands. The self care
program should be based on privacy and dignity considerations such as not breaching the
personal space of Mr.McFarlane and entering in the room while curtains or door is closed for
maintaining privacy. The removal of clothing should be done with a consent and appropriate
hospital gown have to be given. Religious values, gender based concerns and individual views
have to be respected and sensitivity should be there. Importance of personal hygiene should be
taught with regular oral and grooming practices. Pain management has to be administered
before initiating care. Informed consent has to be obtained and appropriate language has to be
used while informing the patients regarding decisions in self care. Referrals to community
resources have to be made considering his existing health condition for programs such as
healthy lifestyle, following a moderate exercise plan, programs to quit smoking and minimize
alcohol consumption. The follow up of patients has to be done periodically through phone, text
messages, email and overall inducing a high motivation level to encourage self-care (Duprez &
et.al., 2017).

Question 4
Mr McFarlane has been identified as being in the higher range of BMI. Calculate Mr
McFarlane’s BMI. With your result, discuss the appropriate strategies to protect his
integumentary system and prevent skin breakdown. Consider what nutritional requirements
should be discussed with Mr McFarlane, considering his obesity, Type II diabetes and poor
dietary intake. Which members of the multi-disciplinary team can assist with support and
education for Mr McFarlane?
In your discussion consider the following:
 Document your calculated BMI
Also consider the following in you answer:
 What is Mr McFarlane’s Waterlow score? What are his contributing risk factors?
 Nursing interventions that could be used to decrease Mr McFarlane’s risk factors for
pressure injuries in line with best practice.
 What information should be provided to Mr McFarlane in relation to his current dietary
choices? Who could assist you with this?
Reference required.
Response:
BMI or Basal metabolic rate of Mr McFarlane is weight in kg/height meter sq., that is 135/170
m sq. = 46.7 kg/m2 is considered extremely high and Mr McFarlane falls in to the category of
morbidly obese (Karchynskaya & et.al., 2020).
Mr McFarlane's Water low score is : 19
 Build/weight for height: 2, Morbidly obese
 Sex and Age: 1, 2 (Male, 53)
 Visual risk areas/Skin type: 1 (Oedematous)
 Mobility: 2 (Apathetic)
 Continence: 0 (Complete) Malnutrition screening tool: 0 (no weight loss)
Special risks
 Tissue malnutrition: Smoker: 5 (PVD) + 1 (smoking)
 Neurological deficit: 5 (Type II Diabetes)

 Major surgery/trauma: 0
The major contributing risk factors include : PVD, Obesity, mobility issues, Smoking, Type II
diabetes (Wang & et.al., 2019).
The strategies that can be used for protecting the integumentary system of the patient and
prevent the skin breakdown are limiting the bath time, avoiding too hot showers or showers for
a very long time and avoiding strong soaps they remove the natural oils from the body.
Grooming has to be done carefully for shaving purposes. Skin creams that are antibacterial and
moisturisers have to be applied. Investigation and management of incontinence also involves
not being harsh on skin or rub anything vigorously and also using pH appropriate skin cleanser
(Davila, 2019).
Nutritional requirements for controlling the obesity and type II diabetes include consultation
with a dietician or advisor, taking a balanced diet, avoiding allergic foods, junk food,
consuming more complex carbohydrates, complete proteins, omega 3 and omega 6 fatty acids
and other healthy fats, eating plenty of green vegetables and fruits with low sucrose.
Other requirements include remaining adequately hydrated, decreasing the consumption of
caffeine, limiting drinking and quitting smoking. The multidisciplinary team that can assist for
the support provision to Mr McFarlane are practice nurses, general practitioner, dietician, and
allied health professionals.
Question 5
Mr McFarlane has pre-existing COPD and on examination you observe that his O2 saturations
on room air are 91%. Consider your nursing interventions, within your EN scope of practice.
How could you assist Mr McFarlane with ease of respiratory functioning whilst lying in bed
and sitting out in the chair?
In your discussion consider the following:
 What are the ‘normal’ ranges for this measurement, comment on Mr McFarlane’s ranges
compare to his SpO2 on admission, and state what actions you need to take.
 How would you demonstrate/ explain the importance of deep breathing exercises and
coughing exercises to the client.
 Which MDT member could assist with active exercises to aid Mr McFarlane’s breathing?

Response:
Oxygen Saturation are a measurement of amount of haemoglobin that carries oxygen in the
blood relative to the amount nor carrying it. The standard value is above 60mm Hg and any
value below it requires supplemental oxygen. The standard oximeter value ranges from 95-
100%. Values under 90% are considered low for functioning properly. spO2 levels of Mr
McFarlane on admission were 96% and post observation the percentage decreased to 91%
while examining again.
Nursing intervention for COPD include:
 Oxygen therapy has to be initiated if the oxygen levels drop less than 88% as for
patients suffering from COPD, spO2 level range is 88-92%. Supplemental oxygen has
to provided in severe cases and carefully managing the equipment, preference to
portable tank and seeing if the airflow is not obstructed (SAH, 2020).
 Raising the head of the bed for promoting effective breathing , descenting of diaphragm
and maximizing inhalation. Positioning will enhance airway patency.
 Deep breathing and coughing techniques have to taught to help Mr McFarlane for
clearing airway through controlled coughing, huffing technique, inspiratory muscle
training, pursed lip breathing and diaphragmatic breathing etc.
 Bronchodilators and corticosteroids have to administered appropriately.
 Management of daily activities with support devices, effective exercise programs,
walking aids.
 Monitoring and managing potential complications by periodical evaluation of cognitive
changes such as memory impairment personality or behavioural changes.
 Pulse oximetry values have to monitored to assess the need for oxygen and manage
administration of supplemental oxygen.
 Prevention of further infections by focussing on immunization of Mr McFarlane
against pneumonia and influenza as he is prone to respiratory diseases.
 The MDT member that can assist with the nursing interventions are allied health
professional and practice nurses.

Question 6
Mr McFarlane has pre-existing osteoarthritis in his L) Knee and is currently on non-weight
bearing activities. Consider your nursing interventions for a client who is unable to weight
bear, within your EN scope of practice. How could active and passive movement exercises
decrease his risk of DVT`s (Deep Vein Thrombosis) and VTE`s (Venous Thromboembolism/
PE’s)?
Consider the following in your answer;
 Active and passive exercises whilst not mobile.
 Which multi – disciplinary member can assist you with implementing the proposed
care?
 What other VTE Prevention measures would be implemented?
Response:
Osteoarthritis is a degenerative joint disease that progresses with deterioration of
articular cartilage present in the synovial joints, and impacts weight bearing joints. Mr
McFarlane has osteoarthritis in his left knee and is presently performing non-weight bearing
activities. Nursing interventions are as follows:
 Assessment of the description of pain of Mr McFarlane and assess the muscle spasms,
paraesthesias, ache or sharp pain in the affected area when brought to full range motion
(Medina-Garzón, 2019). Previous experiences should be assessed with a detailed consideration of pain relief to
devise necessary modifications when pain gets acute.
 Developing a pain relief program on the basis of relieving and aggravating factors
identified by the patient: Usage of hot and cold packs on the affected area periodically
to improve blood flow, reduce pain reflexes, inflammation. Changing positions on
frequent basis to maintain the functional alignment of the patient, eliminating additional
stressors, medication of pain before conducting exercise therapy and other activities.
Supporting joints in flexed positions by using pillows, and towel rolls along with using
adoptive equipments.
 Exercise therapy should include passive and active exercises like cardiovascular

exercises like aqua-jogging, careful physiotherapy. Passive exercises can be
administered through movement of muscles by an outside machine, force or body part.
Active exercises include body movement and muscle exertion like strength training
exercises for the right leg, flexibility exercises like limited leg mobility, stretches and
yoga (Conaghan & et.al., 2019).
 Active and passive exercises have effects on physical and metabolic processes which
tend to improve endothelial function, reducing cardiovascular risks. Evidences from a
comprehensive meta-analysis show direct link and protective effects between regular
physical activity and low incidence of DVT (Deep Vein Thrombosis) and VTE
(Venous Thromboembolism). Other VTE prevention measures include performance
monitoring systems, blood thinners, special tight socks or compression stockings, and
intermittent pneumatic devices for compression. Healthy diet, no smoking proper
hydration are also important (Tanaka & et.al., 2016). The MDT member that can assist
in the interventions are allied health professionals and physiotherapists.
Question 7
Mr McFarlane is generally an active man prior to his admission. Since being admitted to
hospital Mr McFarlane has voiced his concern over being unable to sleep due to his inactivity
and discomfort. What nursing interventions could you implement to promote comfort, rest and
adequate sleep for Mr McFarlane?
Consider the following in your answer;
 Pain management strategies
 Alternative therapies
 Mr McFarlane’s environment
Response:
In order to address the concerns of Mr McFarlane, nursing interventions for promoting rest,
comfort and adequate sleep are are follows:
 Determining the patterns of sleep of Mr McFarlane in normal environment, the bedtime
routine, positions, depth length, aids and interfering factors. Taking notes of sleep-wake

behaviours and total duration of sleep. Noting psychological or physical circumstances
that are hindering sleep apart from discomfort and inactivity.
 Performing a comprehensive pain assessment via PQRST to evaluate provoking
factors, quality, region of pain, severity of pain and temporal frequency, onset and
duration. Along with this a history assessment of pain has to be done.
 Observing the effect of medications and timings, following appropriate medication
schedule. Initiating physical activity through active and passive exercises and slowly
increasing the level of activity. Provision of daytime activities, exposure to natural light
and outdoor environment. Improving the environment around the patient by focussing
on an increased ventilation across room (Hwang & Shin, 2016).
 Measures to relieve pain have to be provided, such as an analgesic prior to the onset of
pain and through physical therapy and postural drainage. As Mr McFarlane suffers
from moderate pain, opioid or a combination of non-opioid and opioid can be
administered without con-analgesics.
 Various non-pharmacological therapies for pain management can be used such as
cognitive behavioural interventions like distraction through reading, Television, games
or guided imagery. Elicit relaxation response to decrease muscle tension and stress
through music therapy, directed meditations, deep breathing, massage and hot and cold
compression can also help in pain relief, acupuncture which increase the quality of
sleep (MacLeod & et.al.,2018).
Question 8
The medical officer has reviewed Mr McFarlane and recommended that he can commence
mobilising for short distances.
Discuss possible safety concerns for Mr McFarlane as he commences mobilising, what
equipment could assist to provide a safer environment and which MDT professional who could
you refer Mr McFarlane to.
Response:
Mobilisation of critically ill patients is aimed at improvement of respiratory function,

functional ability, psychological well-being, increasing consciousness level, and reduction of
immobility related problems. Mobilisation of Mr McFarlane for short distances as reviewed
by the medical officer has been approved but an assessment to address safety factors is needed:
Intrinsic factors
 Medical background: In regards to respiratory issues, Patient has been diagnosed with
COPD and peripheral vascular disease. In case of metabolic issues, patient suffers from
Type II diabetes and in case of musicological disorders patient has osteoarthritis. A
need for mobility equipment is required.
 Cardiovascular and respiratory reserve: Exercise limits have to be suggested on the
basis of resting heart rate and blood pressure. The SPO2 levels of the patient have to be
addressed and if the level deteriorate, modifications to a lower intensity mobilisation
have to be made.
 Haematological considerations of haemoglobin, platelet count, white cell count, blood
glucose level have to be reviewed prior to mobilisation.
Extrinsic factors
 Environment: A thorough assessment of environment where mobilisation will be
carried out has to assessed. The environment should be uncluttered and safe, patient
attachments have to be positioned appropriately and made sufficiently long, appropriate
equipment is required.
 Staffing: for mobilisation of Mr McFarlane sufficient staff has to be made available for
the assistance. The staff has to review and keep informed regarding deterioration or
developments. Concise, clear and calm instructions have to given to the patient to
ensure confidence and general safety and assistance can be given by a physiotherapist
ad practice nurse (Seo & et.al., 2020).
Clinical report documentation.
Date: 1.08.2020
Time: 2 pm
Date: 3.08.2020
Mr McFarlane showed low Spo2 levels , i.e., below 90% and was given
supplementary oxygen. He stabilised after 2 days.
Pain management therapy was provided after giving analgesics as Mr

Time: 11:15 am
Date: 6.08.2020
Time: 6 pm
Date:7.08.2020
Time: 10 pm
Date: 10.08.2020
Time: 11:30pm
McFarlane complained about severe pain on his left knee. Active and
passive exercises on bed have been started.
Blood glucose level of Mr McFarlane was high and a high BP was
observed. Changes in diet advised, decreasing salt and sugar intake.
Wheezing sounds were observed, controlled breathing technique and deep
& diaphragmatic breathing were illustrated to Mr McFarlane.
Mr McFarlane complained regarding sleeplessness due to discomfort and
pain. Pain medications were given along with hot and cold compressions
on the pain area. Sleep medication were given as patient became restless
and anxious. Light physical activities were initiated, dietary changes were
monitored.
Signed: _________________________ Print
Name: _________________________

REFERENCES
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