Assignment: Nursing Care Plan

Posted on: 14th June 2023

Question

Nursing Care Plan

Write a Nursing Care Plan for the following Case Study (see in the end) taking care of the following 5 instructions. Use References using the following text books:

Reference Books to be used for APA style reference and Nursing Diagnosis 

1. Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing    diagnosis handbook: An evidence-based guide to          planning care. (12th ed.) Elsevier.

2. Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lok, J., Tyerman, J., &             Goldsworthy, S. (2019). Medical-surgical nursing in Canada: Assessment and       management of clinical problems (4th ed.). Elsevier.

3. Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. (Eds.). (2019).Canadian     fundamentals of nursing (6th Cdn. ed.) (B. J. Astle & W.Duggleby, Cdn. Adapt.). Elsevier.

4. NANDA for nursing diagnosis 

Instructions:

1. Select a priority problem and using NANDA, write one (1) nursing diagnosis statement in PES format.

An Example of PES format Diagnosis Statement is:  

            Ineffective Breastfeeding related to latching as evidenced by non-sustained suckling at the breast.

2. List the signs and symptoms that support your choice of priority problem.

 Nursing Outcomes - (Goal/Plan)

3. Write one (1) nursing goal for the nursing problem.

4. Write four (4) Nursing Interventions with rationale

5. Evaluation (How would you evaluate the interventions) 

Case Study:

 Adam James is a 60-year-old male who lives alone in 1 bedroom apartment. Adam has history of depression for over 10 years. He has tried to commit suicide twice and his currently seen by a psychiatrist. His wife died 2 years ago and ever since Adam has isolated himself from his friends and is not involved in any social activity. He stopped attending Church which he usually attends weekly. His wife died in car accident for which he blames himself because he was driving the car. Some days Adam says he “wants to die”. He has 2 daughters that live out of Province who calls him frequently. He has a history of Parkinson and has had 2 falls within the past 2 months. He has a history of Arthritis and has joint pain which he takes Advil. He states the pain is controlled with Advil. He reports that some days he feels tired and its difficult for him to get out bed. He ambulates but his unsteady on his feet and uses a walker. He has decreased appetite and takes Ensure with his meals.  According to his daughters when Adam is depressed he forgets to eat. He is forgetful at times and his been investigated for Dementia. His hair looks dull and not combed.

 

 

 

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Solution

Nursing Care Plan

ASSESSMENT DATA

NURSING DIAGNOSIS

NURSING OUTCOMES

INTERVENTIONS

EVALUATION

The patient has a history of depression

Suicidal attempts

Social isolation

He blames himself for his wife's death.

Ineffective coping related to actual loss as evidenced by suicidal attempts, social isolation, blaming himself for his wife's death, and a history of depression.

The patient will refrain from suicidal attempts and interact with family and friends.

 

1. Encourage the client to talk openly regarding his feelings and provide alternative plans for handling frustrations. Initiate an active role in initiating patient communication. This is through speaking to the patient and allowing him adequate time to respond, observe his behavior, and positively encourage him to share his thoughts or write down his feelings.

2. Adequately educate him that addressing depression requires one to openly express his feelings, thoughts, and emotions since it effectively relieves overwhelming symptoms. It provides the patient with positive options for dealing with strong emotions and a sense of control over their actions and lives.

3. Identify why the patient has withdrawn from his family and friends. Please inquire from the patient, his friends, and his family members. It will provide a piece of baseline information on addressing the patient's social withdrawal and isolation. Provide open-ended questions to the patient to explore his thoughts and emotions. Contact and arrange for family and friends crisis counseling. Also, link patient to self-help groups to ensure the re-establishment of social ties and reduces feelings of isolation.

4. Develop a contract of no-suicide with the patient to guide the client on positive actions to take in case of overwhelming emotions. Also, discuss with the patient and family members the available therapy approaches to depression depending on the severity of the client's depression. Constantly remind them that it can be treated, and the patient will return to a normal functional state. Psychotherapy is an intervention that involves a licensed therapist who will help the patient in developing effective coping strategies and mechanisms (Ackley et al., 2020). Pharmacologic interventions include antidepressants such as selective serotonin reuptake inhibitors, which are vital in relieving symptoms and treating depression.

Help the client identify past meaningful things that have given them joy in the past and how they can be incorporated into his current lifestyle to reawaken his experiences to tap areas of creativity and strength and create intrinsic pleasure (Lewis et al., 2019). Consequently, identify a supportive approach and support the patient's efforts in verbalizing and exploring the significance of each ritualistic behavior. For change to happen, the patient needs to recognize and accept the adoption of new perspectives to live positively.

After 72 hours of nursing interventions, the patient verbalizes a feeling of life satisfaction, renews life's realistic goals, and associates freely and socially with friends and family. The patient will demonstrate the adoption of interventions to reawaken positive experiences and promote the current lifestyle.

 

 

History of Parkinson’s disease

Has had falls within the past two months

He is unsteady on his feet and uses a walker.

Impaired physical mobility related to Parkinson's disease is evidenced by the history of falls within the past two months, history of Parkinson’s disease, and unsteadiness on his feet.

The patient will preserve mobility function with minimal complications related to immobility.

1. Teach a wide range of motion exercises and use a wide-based gait to improve balance and prevent accidental falls (Potter et al., 2019).

2. Assist the patient in performing daily exercises to increase muscle strength. These exercises include walking to prevent the development of contractures, reduce muscles' rigidity, and improve coordination. It also delays disease progression.

3. Refer the patient for physiotherapy to help in developing an individualized program for exercise to give instructions to the patient on safe exercising.

4. Help the patient by offering warm baths and massages to provide muscle relaxation and reduce muscle spasms due to muscle rigidity. Educate the family members on the importance of these interventions and how they are helpful to the patient to help them understand and promote the continuation of care to the patient even while at home. 

Within one month of nursing interventions, the patient demonstrates preserved mobility with minimal mobility and improved gait and balance.

He reports being feeling tired on some days.

Joint pain.

He reports difficulty when getting out of bed on some days.

Activity intolerance related to the long-term degenerative disease process as evidenced by joint pain, feeling of tiredness, and difficulty getting out of bed (NANDA).

The patient will demonstrate an improved tolerance to activity and a positive psychological response.

1. Assess the patient's physical mobility to obtain baseline information to formulate goals for a positive patient outcome.

2. Assess the patient's nutritional status, which may contribute. Therefore, educate caregivers to provide a small amount of food frequently and avoid using spices since the patient demonstrates a decreased appetite. Also, the diet provided should be balanced with fruits and vegetables. Adequate energy reserves are required for activity.

3. Encourage the patient to use ambulation aids such as using a walker to enhance his mobility and help him overcome limitations accompanying it.

4. Assess the client's emotional response to limitations in activity performance and reassure the patient since he may develop depression due to the inability to perform activities independently.

 After one week of nursing interventions, the patient demonstrates an improved tolerance to activity. He can perform essential duties such as bathing and dressing and positively accepting his physical state.

References

Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care. (12th ed.) Elsevier.  

Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lok, J., Tyerman, J., &             Goldsworthy, S. (2019). Medical-surgical nursing in Canada: Assessment and management of clinical problems (4th ed.). Elsevier.

Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. (Eds.). (2019).Canadian fundamentals of nursing (6th Cdn. ed.) (B. J. Astle & W.Duggleby, Cdn. Adapt.). Elsevier.

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