Nursing Care Plan: Detailed Patient Assessment and Care Plan

This nursing care plan presents a detailed assessment and care strategy for an 80-year-old male patient, Alexiou Lambros, admitted with submandibular sialoadenitis, alongside a history of stroke, hypertension, and type 2 diabetes mellitus. The report encompasses a comprehensive introduction, detailing the patient's medical diagnosis, age-related risks, cognitive and nutritional status, and mental health. It identifies potential risks such as deep vein thrombosis and surgical complications, and outlines management strategies for pain, insomnia, and nutritional challenges, including both actual and potential problems. The plan includes a detailed nursing care plan template, addressing surgical pain, nutritional and dietary challenges, and insomnia, with specific actions taken and evaluations of outcomes. The goal is to relieve the patient from pain, address nutritional needs, improve sleep hygiene and prevent complications, and ensure wound care. The care plan emphasizes individualized care, and the application of various therapeutic interventions to improve the patient’s overall health and well-being.

Running head: NURSING CARE PLAN 3 1
Nursing Care Plan 3
Name
Professor
Institution
Date
Nursing Care Plan 3

NURSING CARE PLAN 3 2
Part A: Medical Diagnosis (Introduction to the Care plan)
Our hospital, The Kingstone Centre, admitted a patient named Alexiou Lambros (male)
aged 80 on 9th November 2018 as he suffered from submandibular sialoadenitis. The past
medical history of the patient involved a stroke (left hemiparesis), hypertension (HTN) and Type
2 Diabetes Mellitus (T2DM). The patient had dysregulation of metabolism in the form of insulin
resistance and hyperglycemia, which impacted profoundly on the vasculature and structure of his
brain. The patient needed guidance in urinary incontinence.
a. The Age of the Individual
Ageing causes a person high chances of contracting chronic illnesses such as stroke,
diabetes, hypertension, dementia, and depression. These conditions often lead to appetite loss
and inability to swallow, which all result to nutritional status impairment as well as altered intake
of food by the old adults. Alexiou, being aged 80, suffered most of these illnesses. His past
medical history showed that he had suffered from hypertension, stroke and type 2 diabetes
mellitus. He seems to be experiencing life stressors which come in later life of old age, such as
vital capacity loss and functional ability decline (Chambers & Ryder, 2009). The patient suffers
from chronic pain, reduced mobility, frailty and other health challenges that need individualised
long-term care. The psychological distress of being lonely must have caused Alexiou
hypertension due to the associated depression and dementia. Dementia causes an individual to
have a deteriorated memory, behavior, thinking and the capacity to carry out daily activities. It is
familiar for old people as a part of their ageing (Delves-Yates, 2015).
b. Risk Identification

NURSING CARE PLAN 3 3
Using the information gathered about the patient, I found Alexiou to have the following
risks concerning his age, cognitive status, nutritional status, pain, and mental health condition as
well as deep vein thrombosis, pulmonary embolism and venous thromboembolism (Carpenito-
Moyet, 2009).
i. Age
Old age increases the risk to contract chronic diseases such as diabetes, hypertension,
osteoporosis and heart diseases. Alexiou was diagnosed earlier with type 2 diabetes mellitus. He
can stop further advancement of the disease by seeking treatment to control it and improve his
long-term health. Alexiou is at risk of losing his mobility due to osteoporosis which results from
old age. Loss of mobility may be caused by falling, thus fracturing part of the body (Chambers &
Ryder, 2009). Alexiou is therefore at risk of reduced quality of life due to osteoporosis.
Furthermore, as a person advances in age, his risk factors of suffering from heart-related
diseases such as high cholesterol, high blood pressure or stroke, increases. Alexiou, having been
diagnosed earlier with stroke, falls under a high risk of suffering from high blood pressure. All
the conditions can be managed by early diagnosis and treatment as well as living healthily.
Physical exercises such as nature walks, mountain climbing, and jogging help improve body
metabolism and increase physical body fitness (Fero, Herrick & Hu, 2010).
ii. Cognitive Status
As people age, they are likely to experience cognitive impairment which tends to affect
their daily life operations. Additionally, embarrassment, frustration, changes in family roles as
well as social status, bereavement, loneliness and loss of self-confidence can lead the aged to
lose their cognitive status. Alexiou seems to be undergoing cognitive impairment because he had

NURSING CARE PLAN 3 4
contracted hypertension. Reassuring the patient, active engagement of their families in the care
management plan, adjusting the immediate surrounding of the patient to reduce their distress and
reducing stimulation are strategies for the management of cognitive impairment (Barker, 2012).
iii. Deep Vein Thrombosis, Venous Thromboembolism, and Pulmonary Embolism
Alexiou suffered from a stroke, which is heart disease. He, therefore, is at risk of
contracting other heart-related dysfunctions such as deep vein thrombosis, pulmonary embolism,
and venous thromboembolism. Osteoporosis and stroke can lead to paralysis, which causes lack
of muscle contractions, thus preventing the free circulation of blood in the body of the patient.
Due to this, Alexiou is at high risk of blood clots. He can manage the condition by numerous
physical exercises while taking care not to fall and sustain fractures (Bern-Klug, 2010).
iv. Anaesthesia and Surgery
Alexiou had a procedure for a surgical operation to remove the painful lump and unblock
the salivary duct in his submandibular glands. The patient faces the risk of postoperative
cognitive dysfunction due to loss of memory during the surgery (Bern-Klug, 2010).
v. Mental Health Condition
Alexiou is likely to suffer from depression and dementia, which are mental illnesses.
Depression can cause him great suffering and impaired functionality in his daily life. Health
promotion among the aged can help improve the mental health of ageing patients. Creation of
living conditions which support their wellbeing can allow the old to lead healthy lives
(Barker, 2012).
vi. Nutritional Status

NURSING CARE PLAN 3 5
Alexiou, having being diagnosed with diabetes, faces the risk of poor observance on his
restricted nutrition. Due to his old age, he may not be able to consider the diet prescribed for
managing his type 2 diabetes mellitus condition. Besides, the submandibular sialoadenitis is
painful and can cause him not to eat well as required due to the oral pain (Green, 2011). Giving
him individualised care can help manage the condition.
c. Pain Management Strategies
Alexiou suffered from submandibular sialoadenitis which causes blockage of the salivary
ducts to the mouth, thus leading to a painful lump and mouth dehydration (Lewenson & Truglio-
Londrigan, 2016). The following are the strategies to reduce his pain.
i. Cold or Heat Therapy
Applying heat or ice can help reduce pain in patients during surgical operations. Use of
heat therapy improves the pain intensity and function for the patients. Cold therapy using the
Cyro pad also helps reduce pain to patients (Gulanick & Myers, 2010).
ii. Relaxation
There are various methods which significantly help achieve a relaxed response, such as
rhythmic breathing and jaw-dropping. The strategies have likely relaxation impact on pain
(Gulanick & Myers, 2010).
iii. Massage
Massage involves systematically manipulating the soft tissues of the patient through
mechanical or manual means. A rub on the back helps promote patient’s comfort, improved

NURSING CARE PLAN 3 6
blood circulation, and sleep enhancement. Foot and hand massages are alternatives to back rub or
body massage (Priest, 2013).
d. Insomnia Management Strategies
Insomnia often results from clinical depression. Alexiou can manage insomnia by
implementing the following strategies.
i. Sleep Hygiene Improvement
Alexiou can improve his sleep hygiene by consistently waking up at the same time, nap
avoidance, massive exercises during the day and considering bed ritual and relaxation activities
such as reading (Watkins & Cousins, 2009).
ii. Cognitive Behavioural Therapy
The nurse can help Alexiou identify distorted thoughts and reconstruct them into
statements that are more positive and realistic. He should work on his performance anxiety.
Controlling the amount and quality of his sleep is necessary for managing his condition of
insomnia (McLean, 2007).
iii. Sleep Restriction
This strategy helps reduce the amount one spends awake in bed. For instance, Alexiou
can consider initially going to bed very late at night, and waking up at a fixed time (Watkins &
Cousins, 2009).

NURSING CARE PLAN 3 7
Part B: Nursing Care Plan and Template
a. Actual Problems/Issues of the Patient
The patient experienced actual problems such as surgical pain, nutrition, and dietary
challenges and insomnia. I put the patient through a complete pain assessment plan in order to
relieve him from pain. He went through a fluoroscopic insertion of Nasogastric tube (NGT) as
part of the care plan. I also offered him analgesics as per the doctor’s prescriptions. I also
ensured that he was not in stress by involving him in relaxation activities such as a breathing
exercise and jaw-dropping (Stanley, 2016).
The patient experienced nutritional and dietary challenges related to his diabetic
condition and oral pain resulting from the salivary gland lump (Schultz & Videbeck, 2009). Due
to this, he was unable to eat well. The patient received individualised care and pain relief to help
him manage his nutrition. Considering his diabetic dietary restrictions, I managed to help him eat
properly to aid in the quick treatment of the submandibular sialo adenitis which he contracted.
b. Potential Problems/Issues of the Patient
The potential problems that the patient could suffer are the risk for surgical wound-
related infections and the risk for deep vein thrombosis due to his condition of immobility. The
goal of the nurse, in this case, is to minimise the likelihood of the patient to develop deep vein
thrombosis by encouraging him to exercise and mobilise (Gulanick & Myers, 2013). The nurse
also aims at ensuring zero infections on the surgical wound as well as fastening the healing
process of the wound. Doing aseptic wound care as well as maintenance of a proper diet and
nutrition helps reduce wound infections and quicken the healing process (Upton, 2013).

NURSING CARE PLAN 3 8
Identification of the
problem / Issue
Establishment
of Goals
Action Taken Evaluation of
Outcomes
Reflection on
the process
1. Surgical pain The goal is to
relieve the
patient from
salivary lump
pain as soon as
possible.
Complete
assessment of
the pain.
The patient
went through a
fluoroscopic
insertion of
nasogastric
(NGT) tube.
I gave him
analgesics as
prescribed.
I ensured he
was not in pain
and stress by
engaging him
in relaxation
activities such
as jaw moving
and breathing
The patient got
relief from pain
following the
surgical
removal of the
submandibular
gland lump and
unblocking of
the salivary
gland.
I helped the
patient
minimise the
pain that he
suffered.

NURSING CARE PLAN 3 9
exercise.
2. Nutritional
and dietary
challenges
that relate to
the patient’s
diabetic
condition and
oral pain
resulting from
the
submandibula
r salivary
gland lump.
The goal is to
help the patient
eat healthily
and adequately,
with
consideration to
his diabetic
condition and
nutritional
restriction.
Ensure to relief
the patient
from the oral
pain so that he
can eat well.
Help him take
diets which
would help in
the quick
treatment of the
diagnosed
condition of
submandibular
sialoadenitis.
The patient
received oral
pain reliever
and was able to
eat correctly.
Giving him
individualised
care helped
manage his
nutritional and
dietary
restrictions as
prescribed.
Considering
the diabetic
dietary
restrictions of
the patient, I
managed to
help him eat
properly to aid
in the quick
treatment of the
submandibular
sialoadenitis
which he
contracted.
3. Insomnia The goal is to
help the patient
achieve healthy
sleep and
reduce the time
he spends
awake in bed.
Improvement
of sleep
hygiene.
Sleep
restriction.
Cognitive
behavioural
Through sleep
restriction,
cognitive
behavioural
therapy, and
improved sleep
hygiene, the
I helped the
patient sleep
healthily and
reduced the
time he spends
on the bed
before

NURSING CARE PLAN 3 10
therapy. patient
achieved
healthy sleep
habits and
reduced the
time he stayed
awake in bed.
sleeping.
4. The patient
suffers the
risk for
surgical
wound
infections.
The goal is to
ensure zero
infections on
the surgical
wound.
The care plan
also aims at
quickening the
healing process
of the wound.
Carry out
aseptic care on
the surgical
wound as per
the
requirements.
Maintenance of
standard hand
hygiene while
dealing with
the patients
surgical
wound.
Assess the
possible signs
The patient’s
surgical wound
healed properly
without
infections.
I learned much
on the aseptic
care of surgical
wounds as well
as the wound
healing
process.

NURSING CARE PLAN 3 11
of wound
infection and
addressing
them
accordingly.
Maintain a
proper diet to
quicken the
healing
process.
5. The patient
faces the risk
of developing
Deep Vein
Thrombosis
(DVT) due to
possible
immobility.
The goal of this
care plan is to
reduce the
likelihood of
the patient to
develop Deep
Vein
Thrombosis
(DVT).
I am
encouraging
the patient to
mobilise and
carry out
physical
exercises.
Offer health
education to
the patient
about the Deep
Vein
The patient did
not suffer from
Deep Vein
Thrombosis
(DVT) as a
result of the
health
education
offered to him
on its
prevention and
importance of
physical
I learned the
possible ways
of preventing
Deep Vein
Thrombosis
(DVT) such as
mobilising and
carrying out
other physical
exercises for
body fitness
and
metabolism

NURSING CARE PLAN 3 12
Thrombosis
and how to
prevent it.
Encourage the
patient to
engage in
breathing
exercises to aid
in venous
return and
muscle
contractions.
exercise. enhancement.

NURSING CARE PLAN 3 13
References
Barker, S. (2012). Dementia Care in Nursing. Thousand Oaks, CA: SAGE.
Bern-Klug, M. (2010). Transforming Palliative Care in Nursing Homes: The Social Work Role.
New York, NY: Columbia University Press.
Carpenito-Moyet, L. J. (2009). Nursing Care Plans & Documentation: Nursing Diagnoses and
Collaborative Problems. Philadelphia, PA: Lippincott Williams & Wilkins.
Chambers, C., & Ryder, E. (2009). Compassion and Caring in Nursing. London, United
Kingdom: Radcliffe Publishing.
Delves-Yates, C. (2015). Essentials of Nursing Practice. Thousand Oaks, CA: SAGE.
Fero, L. J., Herrick, C., & Hu, J. (2010). Introduction to Care Coordination and Nursing
Management. Burlington, MA: Jones & Bartlett Publishers.
Green, C. J. (2011). Maternal Newborn Nursing Care Plans. Burlington, MA: Jones & Bartlett
Publishers.
Gulanick, M., & Myers, J. L. (2010). Nursing Care Plans: Diagnoses, Interventions, and
Outcomes. Elsevier Health Sciences.
Gulanick, M., & Myers, J. L. (2013). Nursing Care Plans - E-Book: Nursing Diagnosis and
Intervention. Elsevier Health Sciences.
Lewenson, S. B., & Truglio-Londrigan, M. (2016). Practising Primary Health Care in Nursing:
Caring for Populations. Burlington, MA: Jones & Bartlett Publishers.
McLean, A. (2007). The Person in Dementia: A Study in Nursing Home Care in the US.
Toronto: University of Toronto Press.

NURSING CARE PLAN 3 14
Priest, H. (2013). An Introduction to Psychological Care in Nursing and the Health Professions.
London, England: Routledge.
Schultz, J. M., & Videbeck, S. L. (2009). Lippincott's Manual of Psychiatric Nursing Care
Plans. Philadelphia, PA: Lippincott Williams & Wilkins.
Stanley, D. (2016). Clinical Leadership in Nursing and Healthcare: Values into Action.
Hoboken, NJ: John Wiley & Sons.
Upton, D. (2013). Introducing Psychology for Nurses and Healthcare Professionals. London,
England: Routledge.
Watkins, D., & Cousins, J. (2009). Public Health and Community Nursing E-Book:
Frameworks for practice. St. Louis, MO: Elsevier Health Sciences.