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.
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.
- 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.
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
- 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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