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Nursing Care Plan for Nursing Year 1 REHAB FACILITY (…
Nursing Care Plan for Nursing Year 1
REHAB FACILITY (information)
Patient Name: Mrs. X
Age: 92
Code Status: DNR
Marital Status: Widowed
Medical Condition: Right Hip #
Meals: Regular Diet
Fluid Consistency: Regular Fluids
Eye opening: spontaneously
Best Verbal response: oriented
Best motor response: obey
Take meds whole with apple sauce
Adjust oxygen saturation flow to maintain saturation 90-95% (why)
92 yo woman transferred from HRH for right periprosthetic hip #.
? She had previous hip #, dementia with dn PD, fell unwitnessed, on Dec 28, 2022, while walking to the bathroom with her walker. Found to have right hip # and an abrasion to the scalp. Underwent ORIF for right periprosthetic hip #.
27/02/23 ? Nutrition:
Intake Appetite: Intake has been flactuatong ? consuming 50-100% of most meals, receiving supplemental vitamin D, diet tech involved with menu selection
Chewing/swallowing: recent FEES – tolerating regular diet well
Bowel management: last charted BM+today, receiving scheduled lactulose & senna to assist with regularity
Skin Integrity: Skin reported as being intact. Braden = 15
28/02/23 ? Physiological
Received sitting up in chair
1 person assist
Toileted x 1, incont x 1
Took 15mls lactulose instead of 30 mls
Assisted to bed at 2230 at her request
27/02/23 ?Client progress: Continue to progress in therapy. Assist x1 with direct pivot transfer from bed to wheelchair. OT program initiated. PBP done this am; SBP elevated, asymptomatic of BP and with position changes
03/03/23 ? Participated in PT yesterday: “Ambulation: 60 m with 1min standing break + 2min sitting break at halfway point. Steady gait” Seen up in wheelchair, comfortable
Speech and Language
SLP Focus: FEES Study
Fibreoptic Endoscopic Evaluation of Swallowing was completed
Equipment used: Olympus CV-170, flexible nasolaryngoscopy
Procedure was well tolerated and no clear penetration /aspiration
QUESTIONS:
a. Assessment for Gastrointestinal (abdomen; bowel elimination)
b. Genitourinary
Application of Nursing Process/Clinical Judgement Model
–>Diagnosis (Prioritizing Hypotheses) – identifies two priority areas of physiological care for this client
a. Supporting Nutrition
b. Mobility and Ambulation
–>Diagnosis (Prioritizing Hypotheses) – identifies one psychosocial issue relevant to this client
a. Stress and Coping
–>Diagnosis (Prioritizing Hypotheses)
–>Planning (Generating Solution)
a. identifies one goal or desired outcome for the first physiological issue
b. describes, with rationale, the necessary equipment/activities/nursing interventions for addressing the priority issue
c. identifies one goal or desired outcome for addressing the second physiological issue
d. describes, with rationale, the necessary equipment/activities/nursing interventions, for second priority issue
e. identifies one goal relevant to identified psychosocial issue
f. describes, with rationale, the necessary activities/nursing interventions, with rationale, for psychosocial issue
–>Implementation (Taking Action)
a. describes safety interventions that must be considered while providing care to this client
b. two for the nurse
c. two for the client
d. describes three infection control practices that would be used while implementing this care
e. lists four assessments that would be made while providing care to this client
–>Evaluation (Evaluating Outcomes)
a. identifies how outcomes of proposed nursing care plan might be evaluated for each of the 3 identified priority needs
Complete ISBAR included
Introduction
Situation
Background
Assessment
Recommendations
ISBAR must be:
Focused
Concise
Complete
