Integrated Nursing Practice II: Case Study and Care Plan

This case study presents a detailed nursing care plan for a 65-year-old patient with multiple health issues. The assessment reveals the patient suffers from diabetes, hypertension, and COPD, along with a history of a minor stroke, placing him at high risk of cardiovascular disease. The care plan addresses the patient's hyperglycemia, cardiovascular risk, and breathing difficulties. It includes goals such as controlling blood sugar, reducing cardiovascular risks, and supporting respiratory function. Implementation strategies focus on patient education regarding insulin management, dietary modifications, and monitoring vital signs. The evaluation assesses the effectiveness of interventions and the need for continued care. The case study emphasizes the importance of holistic patient care, considering the patient's medical history, current symptoms, and lifestyle factors to provide tailored interventions and improve health outcomes.

Running head: CASE STUDY IN NURSING PLAN
CASE STUDY IN NURSING PLAN
Name of the student:
Name of the university:
Authors notes:

1CASE STUDY IN NURSING PLAN
Case Study of Client: Assessment
A case study of 65-year-old patient was taken for the study and understand the care
plan. At first his blood sugar and blood pressure were checked. The results showed that the
old man was suffering from diabetes and had high blood pressure. He had experienced minor
stroke in the past, which states that he is at high risk of heart related ailments. He complained
of acute shortness in breathing and one year ago he was admitted to the hospital for acute
chronic obstructive pulmonary disorder. The person uses ventilator support every night since
one year since diagnosed with COPD. The person was further asked if he had any major
fever, diarrhoea or abdominal pain to which he replied that he had never experienced severe
problem except for some mild fever, which is common. Upon evaluating the medical history
of his family, it was concluded that he was at high risk of cardiovascular disease but not any
genital disorder. The blood glucose results were not shocking as he showed symptoms of
diabetes like more frequency in urine and tiredness (Adam, Osborn & Welch , 2017). The
patient confirmed that he leads a healthy life by consuming a balanced diet with less
consumption of sugar and fatty substances and goes for walking every morning. He used to
consume tobacco but has left 10 years back. No serious surgeries were performed on him,
however he complained of pain in legs and joints, which make it difficult for him to stand or
walk. This problem is common in this age and may be as a result of osteoporosis therefore he
must consume calcium in food or in the form of supplements. The man is currently under no
medication except for a ventilator system for shortness in breathing. He sometimes take some
medications for mild fever which was prescribed by his physician. The patient’s family
history showed high risk of cardiovascular disease. The patient had high blood pressure and
blood glucose levels as per physical examination. The patient takes ventilator support for
uneasiness in breathing. .He complained of pain in his legs which is common in this age.

2CASE STUDY IN NURSING PLAN
The person does not consume tobacco and leads a balanced life therefore at low risk of
obesity and related illness.
Assessment Diagnosis Goal Implementatio
n
Evaluation
 The patients
family
history
showed high
risk of
cardiovascula
r disease.
 The patient
had high
blood
pressure and
blood glucose
levels as per
physical
examination
 The patient
takes
ventilator
support for
uneasiness in
breathing.
 He
complained
of pain in his
legs which is
common in
this age.
 The person
does not
consume
tobacco and
leads a
Based on
assessment it
is revealed
that the
patient needs
to take care
of his
cardiovascula
r health due
to inadequate
cardiac
output
(Kinchen,
2015
1. The patient
is suffering
from
hyperglycaemi
a and control
of blood sugar
is important
(Allen et al.,
2014)
1a) To verify
the patient
understands the
importance of
taking insulin in
time. Rationale:
identify the
need of change
in insulin.
1b) To make the
person follow
diet containing
low sugar.
Rationale: low
fat diet controls
cholesterol.
(Wong, 2014).
1c) To teach
patient about
adjusting insulin
injection.
Rationale:
multiple
injection causes
fat deposits
(Broderick &
Coffey, 2013).
1A)
Detection of
diabetes
abnormalities
.
1b) Review
of risk
factors
controlled in
the patient.
1c) To
provide basis
for
continuation
of care.

3CASE STUDY IN NURSING PLAN
balanced life
therefore at
low risk of
obesity and
related illness.
2 .To control
the risk of
cardiovascular
disease.
3.To give a
support to his
breathing
problem
2a. To assess
the heart rate
rhythm.
Rationale : to
detect diseases
if present like
atrial fibrillation
or atrial
contractions.
2b) To monitor
urine output.
Rationale:
kidney
responses to
cardiac output.
2c)To monitor
blood pressure
and pulse.
Rationale:
Patients with
renal pressure
are found
hypertensive.
3. a)To assess
the difficulty in
breathing.
Ineffective
breathing
pattern detected.
Rationale: To
detect any form
of disease like
hypoxia.
b)To assess the
respiratory rate.
Rationale: To
detect any form
of disease.
c)To check if
the patient is
2a) To
analyse if the
risk factors
are
controlled.
2b) To
monitor the
blood
pressure and
compare with
past results.
2c) Intervene
if the patient
is facing
difficulty in
daily
activities.
3a) To
evaluate
breathing
pattern.
3b) To check
if he has any
allergy.
3c) To assess
the need of
continued
care.

4CASE STUDY IN NURSING PLAN
allergen to dust
particles.
Rationale: The
analysis of
breathing
pattern helps to
assess the
breathing rate.

5CASE STUDY IN NURSING PLAN
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6CASE STUDY IN NURSING PLAN
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