Nursing Care Plan

Secondary diagnosis: Risk for skin impairment related to physiologic effects of occasional incontinence, immobilization and
circulatory disorder, evidenced by the presence of inflammation, drying of the skin, redness and possible ulcer development in the
coccyx area.

1. Patient is immoderately immobilized. She cannot amubulate for a long time without putting pressure and pain on her right knee. Her condition can lead to risk for
skin impairment since patient cannot turn or reposition herself often on the bed to relieve pressure on certain body areas and this might lead to the development ulcers.

2. Patient has edema in in both legs and especially prominent in the left foot area.

Assessment 3. Patient has moderate control over urination and patient is osccasionally incontinent. This is a huge risk for skin impairment since moisture and bacteria can be
trapped in-between the flaps in the client's perineal area and there is also friction between surfaces, which can lead to impairment of, skin integrity. Signs of redness
and inflammation are observable between the flaps of his perineal area.

4. Patient has a circulatory disorder, diabetes mellitus. This condition leads to reduced perfusion of skin's tissue layers and poor circulation.

5. Patient has patches of dryness in various areas of skin

Short term: to relieve skin dryness that can lead to cracking

Expected Outcomes
Long term: Preserve client's skin integrity and prevent patient from developing ulcers and further skin breakdowns.

1. frequently assists client by changing their position by placing them either in supine, prone or 30 degrees lateral position.
Rational: reduces patient's risk of pressure ulcers.

Nursing 2. palpate area of discoloration: if area does not whiten, this is an early indictor of hyperemia and skin is susceptible to breakdown.

Interventions and 3. Keep the head part of the bed at 30 degrees angle or lower: rationale: this allows the pressure to be relieved around the sacral area
Rationale 4. meticulously clean and thoroughly dry all areas that have been newly washed especially in-between the flaps of client's perineal area: rationale: perineal area must
be cleaned thoroughly since feces host bacteria that may get trapped in-between the flaps. In addition, wet area must be dried comprehensively for it to be an in viable
median for bacterial growth.

5. apply moisturizing cream all over client's body: rational: to reduce patches of dry skin and to prevent cracks.

Evaluation I have performed interventions one, four and five but I was unable to perform interventions two and three due to time constraints. I wasn't able to see a noticeable skin
condition improvement because there wasn't enough time to see a difference.
 Nursing Care Plan
4

Pimary diagnosis: Acute pain in right leg related to musculoskeletal disease (arthritis ) evidenced by immobilization of right leg and
frequent complaint of severe pain when pressure is on the right leg.

1. Client experiencing a sharp pain that varies in pain severity on a day to day basis. Pain scale rating range from 7 to 9.

2. The pain have started two months ago when client was first admitted into the hospital. The duration of the pain is continuous

Assessment 3. During colder days the client states that the pain is worse and client also states that the pain is worse after physiotherapy and occupational therapy

4. Patient always has a grimace on her face when she tries to move her right leg.

5. She is unsteady on her feet when standing and frequently loses her balance.

Expected Outcomes Short term: To raise client's comfort level and to mitigate pain in her right leg.

Long term: To reduce pain siginificantly in her right leg so she can ambulate without difficulty.

1. Reduce pressure on her right leg through methods such as putting her on a wheel chair when needed to travel long distances. Reduce movement of her right leg
when dressing her and transfering her. Rational: Pressure accentuate the pain in her right leg, thus reducing pressure and movement in that area will alleviate her pain
Nursing significantly.

Interventions and 2. Distracting client by engaging her in conversation and other activities such as television or books. Rational: Distraction will allow client to focus on other things as
Rationale opposed to focusing on her pain. Often, the emotional awareness of pain makes pain a much worse experience.

3. Make sure client is always in a cardigan and is covered by a sweater. Rational: client experiences more pain when she is cold, thus making sure the client is warm
will make sure the pain does not get worse.

4. Administer oral narcotis and patch narcotics as orderd by physician. Rational: Pain medication will physiologically reduces pain and works by blocking pain
receptors in the body and allows patients to experience less pain.

5. Seek for holistic pain reduction therapy such as acupuncture or heating pad to supplement her medications. Rational: These methods have little side effects and are
safe pain reduction methods.
Evaluation Most of the nursing interventions have been performed. Client has showed significantly improvement in pain reduction since the first time I've seen her.

Nursing Care Plan

7

References

Jarvis, C., & MacDonald-Jenkins, J. (2009). Chapter 18: Thorax and lungs. In C. Jarvis (1st ed.). First Canadian Edition: Physical

Examination & Health Assessment (). Toronto, ON: Elsevier Canada.

Perry, A.G., & Potter, P.A. ( 2010). Clinical Nursing Skills & Techniques (7th ed). Toronto: Mosby.

Potter, P.A., & Perry, A.G. (2009). Canadian fundamentals of nursing (4th ed.). Toronto: Mosby.
Running head: NURSING CARE PLAN
1

Nursing Care Plan

Jian Li

0481843

Nurs 2530 FA

October 22nd, 2010

Nursing Care Plan
2

Client History

Eileen Fullarton is an 87 year old patient currently undergoing rehabilitation at st.joseph's care group. Her height is 5 ft 8 and

weight is 152.9lb. She has three daughters and is previously lived with her husband Archie Fullarton in Thunderbay, Her husband also

uses a walker. Client has a history of atrial fibrillation that was controlled by Amiodarone. She was on warfarin but it was

discontinued because it made her susceptible to fall at home. She has a history of parkinson's disease and previous cerebral vascular

accident and diet controlled diabetes Mellitus, parkinson's disease, hypertension, myocardial infarction and arthritis. She also had a

right hip replacement in 1980 and in 1982.

Her admitting diagnosis was intractable pain in right leg. Her knee however is limiting her rehabilitation. The pain is getting

worse to the point that she is unable to move her right leg and ambulate without a significant amount of pain. With Xrays evidence,

both knees show osteoporosis with mild bilateral osteoarthritic spurring. There is also narrowing of the medial and lateral

compartment of her knee joint. Her pain also seems to have a history of paraoxysmal atrial fibrillation.

She was on M-Eslon twice daily in the past, but this medication was giving her nausea and so now she was recommended to be
on Tylenol #2 when ever its needed. She also agreed to have a trial of cortisone to her knees.

The goal is for her to return to her home in the community after the period of rehabilitation.

Nursing Care Plan

Current Client Care

Morning routine involves administration of medication, getting client ready for washing. Client experiences significant

difficulty in ambulation and moving her legs. Her bed and chair is usually raised to assist her upon transfering and she is required a

transfering belt for her unsteady balance. Client is on a full diet although frequently expresses concern of the lack of variety in her

meals.

She was appointed with physiotherapy at 10:00 in the morning and occupational therapy at 14:30 every afternoon. I was

directed to administer Tylenol #2 half for client half an hour before therapy because therapy usually adds stress to her knees. Daily

regime also includes application of heating pad to client's knee before 14:30 therapy. Client is also on narcotic patch which is to be

replaced every 4 days to her left shoulder. Other pain reduction methods includes accupuncture, which was to be done twice a week.

She frequently complains of nausea. Gravol is usually administered when needed either orally or subcutaneously. Client

believes it's the pain narcotic that is contributing to her nausea.

Nurse-client relationship is to be terminated on October 22nd, 2010.