Nursing Care Plan 1

Nursing Diagnosis

Patients Initials: Outcomes

Rm. #: Interventions

10/30/2011 Rationale Evaluation

Nutrition: Imbalanced, less than body requirements related to impaired swallowing aeb Pt.s weight 55% below ideal for height and frame; Pt. weights 57 lbs. (40 lbs drop in one year),

1. The client will gain 10 lbs in 2.5 months; a weight gain of 1 lb. each week.

Offer Pt.150 mL thickened pudding between meals at 10:00 & 1500.

Increased calories result in weight gain and prevents further weight loss. Dr. ordered 360 mL Ensure q.o.d. at 20:00HS 3 weeks ago. Since that time Pt. has gained 1 lb

Goal partially met; Pt. has gained 7 lbs in 2.5 months. Now weights 64 lbs.

Call Pt.s doctor today to discuss an increase of 360 mL Ensure from q.o.d. to q.d at 20:00 hr. Weight Pt. every Friday at 14:00

Assess diet with Dr and Nutritionist to look at possibility of a 20-30% higher protein and 20- 30 % higher fat diet this week.

Higher fat diet could result in weight gain and higher protein may result in increased pressure sore healing and prevention.(Despite 2 hr. position changes, air bed and Duoderm dsg changes q. 3 days; Superior and inferior coccyx pressure sores are not healing. )

Encourage Pt. today and family tomorrow to reconsider NG tube feeding again, reminding them of the potential health benefits in addressing Pt.s severe weight loss, difficulty swallowing , loss of skin integrity and increased weakness

40 lb. weight loss in last 12 months despite slow hand feedings, pureed food and thickened liquids, vitamin supplementation and Ensure

Nursing Diagnosis

Outcomes

Interventions

Rationale Increased hydration;

Evaluation

2. The client will increase daily liquid intake by 500mL in 2 weeks

Offer Pt.125 mL thickened apple juice upon waking , before breakfast, at 1500 and 1900. Teach, encourage and remind Pt. how increased hydration can benefit her health and aid in weight gain. Communicate with Pt.s other 2 nurses and family about her hydration needs today.

Hydration encourages sputum elimination which decreases coughing. This will increase ability Pt. to consume higher % of food before tiring and result in increased motor performance and muscle fatigue *see Citation 1

Goal partially met Pt. has increased fluid intake 250mL per day for the past 2 weeks

3. Tissue Integrity: Skin Due to improved nutrition the client will have a decrease in stage II superior coccyx sore from 3cm x 2cm and inferior stage II coccyx sore will decrease from 4cm to 3 cm in 2 weeks time. No further skin openings will occur

Continue with duoderm dressings changes every three days. Measure and document size and appearance of each ulcer on each dsg change.

Increased nutrition aids in skin breakdown repair and prevents further breakdown

Reposition Pt. q 2 hrs. Use slip sheet and good transfer techniques to prevent friction and shearing

Good transfer techniques prevent friction and shearing 2 hr position changes prevent ischemia

Goal met: Superior coccyx sore has closed and inferior sore has reduced to 2cm x 1cm x 0.5 cm deep No further skin breakdown has occurred

Readiness for enhanced Communication: related to decreased ability to swallow, modulate speech and point fingers aeb decreased ability to use prior computer and alphabet pointing sheet communication aides

1. Pt. will regain ability to communicate needs to staff and visitors through augmented communication device in one month.

Communication Enhancement: Speech Deficit: Call Speech Therapist about communication device update options by end of this week.

Speak with Pt., Dr. and sister about advocating for coverage of augmented communication device that does involve typing or pointing.

Pts inability to communicate increases her anxiety, level of depression, social isolation, withdrawn state of mind, appetite, physical health and will to live. Existence of: Augmented Communication devices such as Eye tracking devices that do not involve pointing or typing . *see citation 2

Decreased ability to accurately point at alphabet and needs sheets due to tremors and hand contractures. Pt.s use of non-verbal cuesturning head and moving eyes towards object of need Statements from close friend and former PCA A year ago she could talk, now she cant use her computer and can barely point, she is so depressed

Goal partially met. Medicaid funding for eye track device. Received. Pt. is being taught to use it. Speech Therapist said it will take a few more weeks for Pt. to gain better control of device. Pt. first 2 sentences spoken were : thank you thank you I can communicate again and I want custom cushion for between my legs reordered. It disappeared. Helps pain

2. Pt.s 3 nurses,CNAS and family will use Pt.s friend Ida for interpretation when she is visiting and call her whenever Pt.s needs are in question.

Encourage Pt.s 2 other nurses and 3 CNAs to work with Pt.s close friend Ida for better interpretation of Pt. needs when she visits and to call her if whenever needed.

Ida is Pt. close friend and was Pt.s PCA for nine years and comes to visit regularly. She has an enhanced ability to understand Pt.s wishes/needs. Pts inability to communicate increases her anxiety, level of depression, social isolation, withdrawn state of mind, appetite, physical health and will to live. Pt. s caregivers can anticipate Idas availability in order to communicate more accurately with Pt..

Discuss effects of decreased ability to communicate with Pt. and family. Encourage family to use Ida as interpreter to communicate with Pt. more accurately

Goal partially met. In last 2 weeks onduty Nurses and sister have been asking Ida for interpretation when she is visiting Pt. CNAs have not. No staff has called her at home for help.

Post Idas weekly visiting times at Nurses station for Pt.s nurses and CNAs every Sunday.. Ask Ida to give her weekly visiting times to Pt.s nurse on duty every Sunday when she visits.

3. Pt. will not lose present level of 15 ROM. Pt.s abilty to keep neck and head upright will be maintained and will attend all PT sessions in next 3 wks.

Discuss Physical therapy session attendance with therapist.

Remind Pt.s other 2 nurses and 3 CNAS to continue recommended ROM exercises every morning when Pt. awakes.
Encourage Pt. to continue physical therapy to maintain current level of ROM today and any day Pt. cancels her physical therapy appt.s

The more ROM Pt. has, the less likelihood of more contractures. Eye track communication device works best when Pt.s neck and head remain upright.

Goal partially met; Pt. has maintained 15 ROM and neck and head remain upright. Pt. has missed 2 out of 10 PT sessions.

Reminding Pt. of why PT is important could increase her attendance.

Encourage family and friend Ida to reinforce to Pt., the need for PT. Teach them how to do passive ROM exercises with Pt. on their own 2 or more times a week.

Getting family and friends involved in passive ROM exercise sends message of caring, teamwork and commitment to Pt.s health and will lead to positive effect on Pt.s state of mind and determination to keep present level of ROM in check. Positive reinforcement of new communication skills will motivate Pt. to keep ROM at present level.

Speak to sister tomorrow about having a small family/friend/staff party for Pt. on December 3rd to show off her ability to use new eye tracking device.