(PDF) Nursing Care Plan : Assignment
Added on -2021-01-04
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CARE PLANNING
TABLE OF CONTENTSCARE PLAN FOR HEATHER COOK ..........................................................................................1Nursing Diagnostic statement 1: Acute pain ..................................................................................1Nursing Diagnostic statement 2: Impaired skin integrity................................................................2Nursing Diagnostic statement 3: Impaired urinary elimination ......................................................3Nursing Diagnostic statement 4: Impaired physical mobility .........................................................4Handover of care.........................................................................................................................5Discharge plan ............................................................................................................................7REFERENCES ...............................................................................................................................8
CARE PLAN FOR HEATHER COOK Nursing Diagnostic statement 1: Acute pain Mrs. Heather Cook described the pain level as 7/10 on pain assessment scale. MrsHeather Cook informed that she has community nurses who helped her in bathing, shifting anddoing other routine activities. When she has to wait too long on wheelchair for her home nurse tocome then it causes her great pain because she even cannot shift to bed for her afternoon sleepwithout their support. Expected outcome: From the nursing interventions her pain level will be reduced. She will becomforted. The nursing interventions will help her to minimise the pain which occurredfrequently due to continuous sitting on wheelchair. Nursing intervention 1:The nurses and therapists must provide occasional rest durations inbetween movement. Rationale 1: This intervention will reduce the pain extent of patient. It is essential to regainenergy so that fatigue instances or the sufferings as a result of intense pain can be avoided(Pilutti & Edwards, 2017). The occupational therapists can assist Heather to make her learnabout use of aids and management strategies to deal with pain occurrence and its elimination. Nursing intervention 2: The position of patient must be changed after every two hours. Rationale 2: The periodic movement will prevent ulcer to develop further and it will not moveto next severe stages. It will also encourage mobility. The continuous sitting on wheelchairleads to regular pressure on superior ischium resulting in extreme pain (Gabison & et.al., 2018).If she will increase mobility with the help and support of her home nurse and husband, then itwill give her relief from the pain and discomfort.Nursing intervention 3: Nursing care providers must give assistive devices to the patient. Rationale 3: Heather is suffering from mobility concerns thus aids such as elevated toilet seatsalong with support for arms, shower chair will give her comfort for self-care activities such ashygiene, dressing and toileting. Along with pain relief by limiting regular sitting these aids willgive her balance so she will not fall due to weakness or fatigue. She will be able to performthese tasks with minimum support of nurse and she will instantly perform these functionswithout waiting for the nurse to come. It will also reduce the possibilities of fatigue and patient1
will be able to participate more actively in simple routine activities by elimination of painsources (Hocaloski & et.al., 2016). Nursing intervention 4: Nurse must report frequency of urination, incontinence, burning andforce of urinary stream. Rationale 4:Heather is using catheter care. The patient may suffer from bladder or urinarytract infection. This intervention will indicate the presence of infection so that it can be treatedin initial phase only (Moss-Morris & et.al., 2016). The infection can also lead to pain in urinarybladder and discomfort. The intervention will help to avoid this probability. The timed voidingand bladder training programs will help to restore adequate bladder functioning and eliminationof pain due to urinary tract infection.Nursing Diagnostic statement 2: Impaired skin integrityIt was evident by the patient’s observation. Her skin had non-blanchable redness. Ischialtuberosity pressure injuryof stage 1 can cause affected skin to appear discoloured. This can leadto severe damage to underlying body tissues and skin as the stage of pressure ulcer increases.Skin breakdown, infection and skin integrity alteration are possible risks of the diagnosis.Expected outcome: With the below nursing interventions, Mrs Heather Cook will be providedadequate care for healing of wound developed due to pressure ulcer. It will also regulate thatpressure ulcer does not turn more severe by shifting into next stage. Skin itching will be reducedwithin few hours and skin breakdown or infection will normalise within few days.Nursing intervention 1: Nurses and carers must place soft cushioning between bony regions Rationale 1: The regular sitting on wheel chair can cause pressure ulcer in the regions of anklesand wrists as well. The attachment of sheepskin to hard surfaces such as wheelchair sides willhelp the patient to reduce the pressure development (Gabison & et.al., 2017). It will avoid theshear amount and friction due to these hard elements on skin. Nursing intervention 2: The skin of patient must be kept wetness free. For this, moisture mustbe assessed. Nurses must apply non-caking powder on skin parts which touches each other. 2
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