University Nursing Care Plan: HLTENN004 Report on Mrs. Martin

This report presents a detailed nursing care plan for Mrs. Renee Martin, an 80-year-old widow with dementia, who recently underwent knee replacement surgery. The report addresses several critical issues including the patient's age-related risks, cognitive status, and the complications arising from her surgery, such as deep vein thrombosis (DVT), fall risk, and immobility. It outlines actual and potential problems, establishes goals, details the actions taken, and evaluates outcomes. The care plan includes interventions like medication management (donepezil, memantine, pain killers, blood thinners), fall prevention strategies, physiotherapy, and nutritional support. The report emphasizes the need for a holistic approach to patient care, involving both medical and supportive measures, and highlights the importance of a safe environment and assistance to execute daily activities. The plan also addresses potential issues like weight gain and insomnia, providing strategies for their management, such as diet modification and sleep medication. This report provides a comprehensive overview of the patient's condition, the care provided, and the reflections on the processes involved.

Running head: NURSING
Nursing Care Plan 3 Clinical Placement
Student Name
University Name
Student Note

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NURSING
PART A
Mrs. Renee Martin is an 80-year-old widow, who recently had a knee replacement surgery. Ever
since the surgery, she had been suffering from tenderness and swelling in her calf muscles and
legs. Five years ago, she was diagnosed with dementia, which has progressed drastically over the
period. Considering her psychological condition, she is at a great fall risk after her knee
replacement surgery that she often tends to forget. As a result, there have been several scenarios,
where she has tried to walk at a faster pace, causing her to fall, and leading to bruising on her legs
and arms. Due to the frequency of her falls, the symptoms of deep vein thromboembolism went
unnoticed by her doctor, causing her to become more and more agitated with pain on her legs.
Due to frequent complaints of severe pain in leg and calf muscles, she was admitted to the
hospital.
Age :
Risk: Age is considered as one of the most important risk factors of neurodegenerative diseases
like dementia. It has been seen that dementia is most common in age range of 65 to 90. This
disease progresses as years go by, deteriorating the memory retention capacity of the patients.
Management: The best way to manage a dementia patient is by understanding the different
behaviours of the patient. Dementia unlike Alzheimer’s is curable and thus medications like
donepezil and memantine can help reduce the effects of this disease.
Anaesthesia and surgery
Risk: This case subject, Mrs Martin has suffered from a condition of formation of blood clot in
her legs due to the improper conduct of her knee replacement surgery.
Management: Healthcare providers like nurses and doctors should ensure the proper execution of
surgeries in order to prevent cases like this. Studies have observed that general anaesthesia in
cases of knee replacement surgeries prevents after surgery complications like clot formations or

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increased pain or swelling.
Cognitive status
Risk: As a dementia patient, who is not yet taking any medications of for this disease, she is
bound to lose control over the basic cognitive skills like thinking and remembering, eventually
leading to cognitive impairment.
Management: Ensuring she takes medications like donepezil and memantine, timely and in right
doses.
Deep vein thrombosis, venous thromboembolism, pulmonary embolism
Risk: In these conditions the blood clot formed can reach the lungs causing respiratory
complications.
Management: Compression stockings and blood thinner medications like warfarin and heparins.
Immobility & pain
Risk: The pain from the deep vein thrombosis and knee surgery can make the individual very
agitated and given her condition, it will become harder to contain her. This can also affect her
sleeping pattern as the pain might not allow her to sleep properly.
Management: Pain killers and blood thinners can be prescribed.
Length of stay
Risk: In the hospital, she might need to stay for 6-10 days, given her age and decreased healing.
After release, she would require an assistance for her safety.
Management: During the length of her stay as well as her prolonged recovery period, she would
require assistance regarding the execution of her day to day activities.
Mental health condition
Risk: She tends to forget easily due to her dementia.
Management: Dementia unlike Alzheimer’s is curable and thus medications like donepezil and
memantine can help reduce the effects of this disease, and enable the stabilization of memories.

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NURSING
Nutritional status
Risk: During the recovery period, she would require to eat a low fat diet.
Management: The nurses should provide the patient with a calcium rich, low fat diet along with
vitamin supplements.
Presence of morbidity, & non-compliance
Risk: Due to her dementia she often forgets to take her medications, and even eat, causing
detrimental effects on her health.
Management: Administering a personnel care giver to ensure that the patient eats food and takes
her medications timely.
Maintaining a safe environment, including risk prevention strategies:
 Providing safety companions to prevent trips and falls.
 Low- fat diet to prevent weight gain during the recovery time for knee replacement
surgery.
 Physiotherapy training to prevent complete immobilization of the patient.

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PART B
Actual Problems/Issues:
Identify
problem /issue Establish Goal Take Action Evaluate
Outcomes
Reflect on
process
Dementia The goal is to help
her execute her day
to day activities.
Considering that age is
one of the most
important risk factors of
neurodegenerative
diseases like dementia.
 Holistic approach:
Administering
drugs, like
donepezil and
memantine to bring
back the chemical
balance in the brain
that might result in
memory
stabilization and
retention.
 Providing
assistance and
support: to help her
She would be
assisted to take
her medications
on time.
Professional
caregivers will
be present to
take care of her
needs and help
her execute her
day to day
activities.
Due to the
frequent
monitoring she
would also not
have a risk of
falling.
She
sometimes is
very receptive
of what she is
told, which
has made it
easier to help
her with her
daily chores.

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with her daily
chores and provide her
with the required
assistance. Considering
she is a widow, with no
children or family to
take care of, she would
require a 24/7
assistance, given the
progressive nature of
her disease. She can
thus be, admitted in a
supported or assisted
care living home, where
professional caregivers
will be able to help her.

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Pain due to:
 Knee replacement
surgery
 Deep vein
thromboembolis
m
The goal is to reduce
pain in her knees,
and eliminate the
blood clot in her legs
and calf.
 For reducing the
pain in her knees,
the doctor has
prescribed pain
killers. Thus
considering she is a
dementia patient,
nurses would need
to ensure timely
intake of these
medicines.
 For her treating her
deep vein
thromboembolism,
she can be provided
with compression
stockings or by the
administration of
the correct dose of
blood thinning
medications or
anticoagulation
agents like
Warfarin, and
Heparin.
Even though
temporary relief
can come from
the pain killers
prescribed to
Mrs Martin for
the knee surgery,
it would take
some time for
the knee to heal
and thus a
persistent pain
might remain
during this
period.
The blood
thinners of the
compression
stockings can
help effectively
cure deep vein
thrombosis.
Sometimes
she would get
agitated and
take off her
compression
stockings.
Other than
that she has
been very
cooperative
wit te whole
process.
Signs of relief
can be seen,
judging by
the reduced
complaints
about pain in
her calf
muscles. This
pain
management
has also
increased her
willingness to

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sleep.
Fall risk The goal is to
prevent her from
falling.
The best way to ensure
her from not trying to
walk at a faster pace is
to provide her a
personal caregiver, who
would assist her to
walk. Even equipment
like walkers might help
her maintain her
balance while walking.
She has not
suffered from
any falls or trips
since personal
assistance have
been provided to
her. She has
been responding
well to her
physiotherapy
sessions.
Even though
she has been
observed to
have been
overexerting
herself
sometimes,
she has been
very
corporative
throughout
her
physiotherapy
sessions.

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Potential problems/ issues:
Identify
problem /issue Establish Goal Take Action Evaluate
Outcomes
Reflect on
process
Immobility leading to
lethargy and issues
like bedsores.
The goal is to help
her regain her
mobility after her
knee surgery and
pain in her calf
muscles due to a
condition called deep
vein thrombosis.
She would require to
be given
physiotherapy, to
prevent any stiffness or
swelling in the knee
area and to help her
regain her mobility.
With the help of
effective
physiotherapy
sessions, she
would be able to
help use her foot
muscles properly.
After some
months of
physiotherapy,
she would be able
to walk with the
help of her
walker, without
any assistance
from caregivers.
She has been
seen to be
very
cooperative in
her
physiotherapy
sessions.

9
NURSING
Weight gain The goal is to
prevent sudden
weight gain of the
patient.
After the knee surgery,
she was told to take
bed rest for more than
8-9 months, along with
weekly physiotherapy
sessions and then 2-4
months of practicing
walking. This large
period of 12 months,
with almost no
physical activity, is
bound to result in
sudden weight gain of
the patient. The only
way to control it is by
diet. She should be
given a calcium rich,
low fat diet, with
vitamin supplements.
The incorporation
of a low fat diet
will help prevent
the storage of
extra fats in the
body of the
patient and ensure
reduced weight
gain. The patent
should be
provided with
mainly fluids
rather than solid
foods as she is
required to
remain in bed rest
for a span of
almost 12
months.
The patient
has not put on
much weight
and weighs
4kgs more
than she used
to before.
Thus, diet
modification
for this
patient was
highly
successful.

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NURSING
Insomnia The goal is to help
the patient sleep well
in order for to reduce
her agitation and
irritation.
Sleep medications
have been prescribed
to her. However, after
the administration of
the pain killers and the
anticoagulation agents,
the pain in her legs
which used to keep her
awake all night has
reduced, making it
possible for her to
sleep well.
These
medications have
allowed her to
have sound sleep
at nights.
After the
administratio
n of pain
killers as well
as the
compression
stockings, he
has been seen
to sleep well
at nights.