Rehabilitation and Community Care: Nursing Care Plan (NSG 3101)

This presentation focuses on a nursing care plan for a patient in a rehabilitation setting, likely addressing the needs of a patient with Traumatic Brain Injury (TBI), including challenges like dysphagia and dysphasia. The care plan encompasses various aspects of patient care, including mobility, feeding, and speech. The assignment involves a presentation and a written component, detailing assessment, planning, implementation, and evaluation of nursing interventions. The case study involves a 48-year-old male, Paul, who experienced a TBI. The presentation likely covers aspects of patient assessment, goal setting, intervention strategies, and evaluation of outcomes, considering the patient's physical and cognitive impairments, as well as the involvement of family members in the care process. The provided references support the evidence-based approach to rehabilitation, covering topics such as dysphagia rehabilitation, assessment tools, and the impact of chronic conditions on patient outcomes.

NSG 3101 –
REHABILITATION AND
COMMUNITY CARE
ASSIGNMENT 2 NURSING
CARE PLAN PRESENTATION
Name of the Student
Name of the University

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Patient details
Demographics
NOK
Past medical history
Paul is a 40 year old male
Suffered from accident at
work
Dysphasia, severe
dysphagia and left sided
weakness
Supportive husband who
looks after their daughter
Family history of
hypertension, cardiac
complications and bowel
cancer

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
CNS
 Sedation Neurological
Status GCS
 Mental State / Behaviour
 Pain Score / Analgesia
 Investigations
GCS 9-12
Traumatic Brain Injury
the reason for admission
No noticeable mental
deficits
No history of mental
disorders
Problems in speech and
swallowing due to the
accident
Non-instrumental swallowing
assessment (Heckathorn, Speyer,
Taylor & Cordier, 2016)
Feeding tube and exercise (Souza et
al., 2019)
Videofluoroscopy
Progressive Aphasia Severity Scale
(PASS)
Speech and language therapy
(Nickels & Croot, 2017)
Numeric Pain Rating Scale (NPRS)
(Cleland, 2018)
Occupational therapist
Speech therapist
Dietician
Nurse

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Respiratory
 Oxygen therapy
 Chest x-ray
 Work of breathing
 Lung assessment
 Sputum
Patient does not have
any history of respiratory
disorder
Restricted mobility after
discharge from acute
setting has increased
risk of pneumonia and
dyspnoea (Garcia et al.,
2017)
Comprehensive respiratory
assessment
Blood tests for bacterial infection
Airway assessment for patency
mMRC Dyspnea Scale (Yasui et al.,
2019)
Nurse
Pulmonologist

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
CVS
 Heart rhythm
 Heart rate
 ECG
 Fluids
 Blood pressure
 Circulation
Comorbidity of
congestive heart failure
with dysphagia is quite
common. Thus patient
needs to be diagnosed
for heart functioning
(Castagna et al., 2019).
History of hypertension
and cardiac issues
increases risk of
disability and death.
Monitoring of vital signs
All-inclusive cardiovascular
examination
CVD risk assessment (Rezaee,
Takeh, Putrenko, Ganna & Ingelsson,
2019)
Continue hypertension medications
Cardiologist
Pharmacy

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Renal
 Urine output
 IDC
 Continence
 Frequency
No impairment or
continence issue
observed
Restricted mobility after
release
Constant supervision on continence
status owing to impaired movement

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Metabolic
 TPN
 Afebrile/febrile
 BGL
Symptoms of diabetes
can get exacerbated due
to inflammation, stress,
surgery, decreased
mobility, and metabolic
changes (Rau et al.,
2017)
Laboratory tests Pathologist
Endocrinologist

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
GIT
 Constipation
 Diarrhoea
 Vomiting and nausea
 Fluid and diet intake
 Output
Owing to the common
symptom of weight gain
following TBI, patient
must be given a healthy
diet (Driver, Reynolds,
Douglas & Bennett,
2018)
Impaired mobility can
affect bowel
incontinence (Dibley,
Coggrave, McClurg,
Woodward & Norton,
2017)
Use of analgesic might
Bowel chart maintenance
(Namasivayam & Nandhini, 2017)
Analgesia monitoring
Nurse
Dietician

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Integumentary
 Hygiene
 Perfusion
 Skin integrity
 Wounds
Limited mobility hinders
grooming and dressing
Wound assessment
ADL assessment (Mlinac & Feng,
2016)
Physiotherapist
Dermatologist
Wound consultant

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Musculoskeletal (ADL and
mobility)
 Gait
 Fall risk
 Movement and transfer
 Status
Tried using 4-wheel
walker
Needs assistance during
transfer
Restricted mobility
affects ADLs
Fall-risk assessment (Poe et al.,
2018)
Transfer and movement assessment
Providing walking aids
Range of motion exercise (ROM)
(Uyar & Yakşi, 2017)
ADL assessment (Mlinac & Feng,
2016)
Physiotherapist
Occupational therapist

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Psychosocial
 Emotional support
 Social support
 Family and relatives
 Orders for resuscitation
Patient sent to inpatient
rehabilitation
Has a caring and
supportive husband who
is responsible for looking
after their daughter
Husband recognises the
coping struggles that the
patient has to endure
Daughter pays visit often
but does not stay for
long
Mental health assessment
Emotional Regulation Questionnaire
(ERQ) (Gouveia et al., 2018)
Consider the need for pastoral care
or spiritual care (Jones, Pryor, Care-
Unger & Simpson, 2019)
Social workers
Psychologist
Counsellor
Spiritual leader

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Care plan
 Planned appointments
 Allied health planning
 Medical referral
 Medical consideration
Other assessments that
are required
Medical tests needed
Further referrals that had
not been made
Additional assessments and follow-
up referrals must be completed
Occupational therapist
Physiotherapist
Social worker
Allied health staff
Pharmacy

Summary Nursing diagnosis Nursing interventions Additional Team
Members Involved in
Care Aspects
Discharge planning
 Home support
 Discharge referral
 Supplies transport
 Patient education
Provide the services that
are needed
Install home supports
Safe transition to home
from hospital
Involving family in
discharge process
Address anticipated
healthcare needs

References
Castagna, A., Ferrara, L., Asnaghi, E., Colombo, V., Rega, V., & Fiorini, G. (2019). Post-stroke dysphagia rehabilitation in the old and oldest old: outcome and relevance for discharge home. International journal of rehabilitation research.
Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation. DOI: 10.1097/mrr.0000000000000385
Cleland, J. A. (2018). Reliability, construct validity, and responsiveness of the neck disability index and numeric pain rating scale in patients with mechanical neck pain without upper extremity symptoms. https://
spinalmanipulation.org/wp-content/uploads/2019/01/reliability-construct-validity-and-responsiveness-of-the-neck-disability-index-and-numeric-pain-rating-scale-in-patients-with-mechanical-neck-pain-young-et-al-2018.pdf
Dibley, L., Coggrave, M., McClurg, D., Woodward, S., & Norton, C. (2017). “It’s just horrible”: a qualitative study of patients’ and carers’ experiences of bowel dysfunction in multiple sclerosis. Journal of neurology, 264(7), 1354-1361.
https://doi.org/10.1007/s00415-017-8527-7
Driver, S., Reynolds, M., Douglas, M., & Bennett, M. (2018). Describing weight loss attempts and physical activity among individuals with TBI prior to participation in a weight-loss program. Journal of Head Trauma Rehabilitation, 33(1),
E36-E43. https://doi.org/10.1097/HTR.0000000000000327
Garcia, I. F. F., Tiuganji, C. T., Simões, M. D. S. M. P., Santoro, I. L., & Lunardi, A. C. (2017). Systemic effects of chronic obstructive pulmonary disease in young-old adults’ life-space mobility. International journal of chronic obstructive
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Gouveia, V. V., Moura, H. M. D., Oliveira, I. C. V. D., Ribeiro, M. G. C., Rezende, A. T., & Brito, T. R. D. S. (2018). Emotional Regulation Questionnaire (ERQ): evidence of construct validity and internal consistency. Psico-USF, 23(3), 461-471.
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Heckathorn, D. E., Speyer, R., Taylor, J., & Cordier, R. (2016). Systematic review: non-instrumental swallowing and feeding assessments in pediatrics. Dysphagia, 31(1), 1-23. https://doi.org/10.1007/s00455-015-9667-5
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Namasivayam, S., & Nandhini, G. (2017). BLADDER BOWEL DYSFUNCTION-A PRACTICAL APPROACH. Indian Journal of Practical Pediatrics, 19(2), 183. https://
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Nickels, L., & Croot, K. (Eds.). (2017). Clinical perspectives on primary progressive aphasia. Psychology Press. https
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