Nursing Assignment: Patient Care Plan, Diagnosis, and Goals

This nursing assignment presents a comprehensive patient care plan utilizing the SOAPIE framework. It begins with subjective and objective data collection for a patient who sustained a major head injury and exhibits symptoms including an unconscious state, soft tissue injuries, and elevated blood pressure. The assessment reveals a GCS score of 9, indicating moderate brain injury, and highlights concerns such as elevated blood glucose levels, an inflamed wound on the right leg, and the risk of falls. The plan focuses on controlling blood pressure, managing blood glucose, and treating the wound. Interventions include administering 5% dextrose, antibiotics, and Benazepril. Nursing diagnoses address the risks of falls, hypertension, obesity, and wound deterioration. Goals of care encompass fall prevention, blood pressure regulation, obesity management, and wound healing. Interventions involve assessing mobility, removing fall hazards, administering medications, implementing dietary changes, and providing wound care. References to relevant nursing resources are also included.

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of the Student:
Name of the University:
Author Note:

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Response a:
Admission Summary using the SOAPIE Framework: The SOAPIE framework works on
developing an understanding based on subjective data, objective data, assessment, plan,
intervention and evaluation (Lenthall et al., 2015)
S Subjective Data  The client is an
unconscious state
because of sustaining
a major head injury
on account of a fall
from the escalator
 Presence of soft
tissue injuries around
the neck region
 Presence of
laceration on arms
and legs
 Deep wound on the
outer side of the
lower right leg
 No presence of
fractured bone in the
skull as evident from
CT scan and X-ray
O Objective Data  GCS score
equivalent to 9
 Pulse range between
80-92 minutes per
minute
 Responding to
painful stimuli,
unconscious
 Recorded respiration
rate, 18-20
respirations per
minute
 Recorded blood
pressure: 180/120
mm Hg
 Presence of red areas
on sacrum and heels
 Oxygen saturation
recorded to be 97%
within the room air
 FWT revealed
increase in glucose
level

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 The deep wound on
lower right leg is
seen to be inflamed
and oozing fluid
discharge
 Urine output is
recorded to be higher
than 30mls/hour
A Assessment The laceration and would
marks are seen to improve,
however the wound on the
right leg is seen to worsen
and shows no improvement.
The blood pressure is
elevated and the GCS score
9 indicates moderate brain
injury. The glucose level in
the blood is high and the
body temperature is slightly
elevated. The respiratory
rate as well as the pulse rate
is recorded to be fairly
normal. The blood pressure
level needs to be controlled
and the blood glucose level
also needs to be controlled
on an immediate basis.
P Plan A change is needed in the
plan prioritizing the control
of blood pressure and the
glucose level in the blood.
The wound on the upper
right leg must also be
treated on a priority basis so
as to speed up the process of
recovery. Pain score
assessment must be carried
out on an hourly basis.
I Intervention Interventions used for the
patient comprised of the
administration of 5%
dextrose and antibiotic
intravenously.
Administration of
Benazepril would
effectively help in
normalising the blood
pressure.
E Evaluation The client is moderately
febrile and is showing signs

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of improvement. The
wounds and lacerations are
seen to improve. However,
the elevated blood pressure
and glucose level need to be
kept under control. It can be
expected that administration
of Benazepril can help in
normalising blood pressure
and at the same time reduce
risks associated with renal
complications.
Response b:
Nursing
Diagnosis
Goals of care Nursing intervention Rationale
1.Increased risk
for fall and
related accidents
causing physical
injury
(Falls risk)
Elimination of
hazards that could
cause fall related
accidents
 Thorough
assessment of
the patient’s
mobility skills
to determine
whether or not
the patient is
capable of
mobilising
independently
or is in need of
some form of
support.
 Removal of
risk-elements
such as rugged
mats or carpets
that could
cause tripping
over and lead
to a fall
 To thoroughly
ensure that the
patient is
wearing
comfortable
shoes that
would help in
the process of
walking
 Conduct a
 Movement
assessment
would help
in devising
an
appropriate
intervention
plan for the
patient
 Removal of
obstacles
such as
rugged mats
with lose
ends and
carpets
would help
in ensuring
a safe
environment
and reduce
risks
associated
with fall
 Studies
suggest that
proper
shoes can
help in
ensuring
safety and

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2. Elevated blood
pressure and risk
related to
hypertension
(blood pressure
risk for unstable)
Regulation of the
blood pressure
level in order to
avoid cardiac
complications
thorough
vision check
so as to make
sure that the
patient is able
to see clearly
 Ensure proper
lightening
within the
home
environment
so as to make
sure that the
patient does
not trip over
and fall.
Administration of
medications such as
Benazepril and
Captopril in order to
control the elevated
blood pressure. At the
same time also
reducing the intake of
salt and increasing
water intake
reduce risks
associated
with fall and
accidents
(Ackley et
al., 2016). It
is important
that the foot
is placed
within a
comfortable
shoe which
would
facilitate
slight foot
space in
order to
make sure
that the
movement
is smooth
and does not
cause injury
 Vision
check and
proper
lightened
environment
would
ensure
safety and
reduce risks
associated
with
tripping or
falling
Benazepril is an
angiotensin-
converting-enzyme
inhibitor that is
used for the
treatment of
hypertension and
cardiac
complications
(Ackley et al.,
2016). Benazepril
is a pharmaceutical
drug that falls

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3. Effective
management of
excessive body
weight and
obesity concerns
in order to
mitigate risks
related to
hypertension
(Obesity)
4.Ensure proper
wound
management so
as to avoid
further
deterioration and
risk related to the
development of
sepsis
(Pain)
Introduction of an
effective nutrition
plan in order to
manage obesity
related concerns
and effectively
manage excessive
body weight
To reduce
inflammation and
cease the discharge
of exubate. To heal
the wound on the
outer surface of the
right leg.
 Engagement of
a dietician for
the
incorporation
of a strict diet
plan in order
to restrict
calorie intake
 Complete
cessation of
alcohol intake
 Engagement of
a
physiotherapist
so as to
administer
minimal
exercises for
regular fitness
Administration of
proper wound care so
as to prevent the
deterioration of the
condition and the
possibility of
deterioration of the
condition on account
of delayed or slow
recovery process.
under the category
of angiotensin-
converting enzyme
inhibitor
pharmaceutical
drug category. The
drug elicits its
effect by relieving
the blood vessels
and decreasing the
blood volume. This
consequently leads
to the lowering of
the blood pressure
and at the same
time also prevents
any chances of
bursting of the
blood vessels and
capillaries or any
possibility of heart
related disorders.
Obesity has been
reported to be
tightly linked with
hypertension. The
client has gained 20
Kilos recently and
has been reported
to consume alcohol
frequently (Ackley
et al., 2016).
Controlling the
body weight can
help in avoiding
problems related to
elevated blood
pressure and
hypertension.
A number of
factors such as
obesity and
elevated blood
pressure or cardiac
complications
delays the healing

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process (Ackley et
al., 2016). In
addition to this high
blood sugar level
also interferes the
wound healing
process. Therefore,
it is extremely
important to control
these factors along
with devising
medication to
control
inflammation and
pain of the wound.

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References:
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2016). Nursing Diagnosis Handbook-E-
Book: An Evidence-Based Guide to Planning Care. Elsevier Health Sciences.
Lenthall, S., Knight, S., Foxley, S., Gordon, V., Ivanhoe, T., & Aitken, R. (2015). The remote
area nurse model of consultation. International Journal of Advanced Nursing
Studies, 4(2), 149.