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Case Study Nursing Care Plan

Health History & Current Medical Diagnosis.

  • Health History
  • COPD
  • HTN
  • IBS **
  • Depression
  • Deaf-Left ear (Cochlear implant)
  • Celiac **
  • Right Hip Replacement
  • Small bowel obstruction
  • Aspiration Pneumonia
  • Malnutrition

Admitting Diagnosis.

Left Hip Fracture

Current Diagnosis.

Hip Dynamic Screw

Overview of Presentation.

  • General patient information
  • Patient History
  • Assessment findings
  • Diagnosis
  • Goals
  • Expected Outcome(s)
  • Nursing Interventions
  • Evaluation of goals
  • Application of a nursing model

Evaluation.

Nursing Actions.

Patient Response and Finding.

Implementation (for diagnosis #1).

  • Occasionally ask L.P about feelings.
  • She states that she is feeling energetic and is willing to attend group activity.
  • Weigh L.P
  • L.P gains over 2 pounds in a month
  • Observe L.P's daily oral intake.
  • She consumes up to 1/2 of meals and finishes high protein and high caloric food items.

ECG

  • Observe L.P's physical appearance.
  • Patient appears to have more subcutaneous fat

62

bpm

Priority Patient Needs.

Key Assessment Findings.

Orem's Self Care Model.

  • Physical: Ensure that the patient is obtaining a sufficient amount of nutrients on a daily basis
  • Psychological: Positive reassurance regaring her current situation.

Objective Data.

Subjective Data

Planning (for diagnosis #2.

Hopelessness related to long-term stress, as evidenced by negative statements of current situation.

Possible Nursing Diagnosis.

  • “I have alway been skinny but I have lost a lot of weight in the past few years”
  • “There’s no point anyway...it won’t change anything.”

  • Addresses the ways in which people are responsible for meeting self care goals.
  • The outcome of all nursing actions should promote self care in order for the patient to become independent.
  • Times that nursing care is needed:
  • Acting for and doing for others
  • Guiding others
  • Teaching
  • Supporting another.

  • Severe muscle weakness (lower extremities only)
  • Limited mobility (most likely a result of muscle weakness)
  • Impaired hearing
  • Vital Signs constantly stable
  • Severe pain (only during transfers)
  • Mood changes
  • Knowledge deficit regarding necessary nutrients
  • Eats only about ¼ of meals

Lab Values.

  • Malnutrition
  • Impaired mobility
  • Fear/anxiety
  • Depression
  • Hopelessness

  • Low RBC count **
  • Low potassium leels
  • Low sodium levels

Priority Nursing Diagnosis.

  • Imbalanced nutrition related to decreased oral intake as evidenced by physical appearance.

References.

Potter A., Perry A.(2016) Imbalanced Nutrition. In Canadian Fundamentals in Nursing.(pp. 1067-1072). Toronto ON: Elsevier.

Urian L., Buiga H., Claudia B.(2016). Severe Iron-Deficiency and Anemia. International Journal of Celiac Disease. 4(1), 27-29.

  • Hopelessness related to long-term stress, as evidenced by negative statements of current situation.

General Information.

Planning (for diagnosis #1).

Implementation (for diagnosis #2).

Imbalanced nutrition related to decreased oral intake as evidenced by physical appearance.

  • Patient Initials: L.P
  • Gender: Female
  • Age: 55
  • Allergies
  • Food: Shellfish, Seafood, Gluten
  • Medications: Levofloxacin, Anafranil, ASA-aspirin(Stomach ulcer).
  • IYM Status: 1PA
  • Diet: High Protein, High Calorie, Minced Diet, Ensure +235ml Daily Calorie Counts

*

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