Nursing Care Plan Presentation

Background

• 24-year-old male professional athlete admitted to the hospital with acute respiratory distress syndrome

• Tested positive for COVID-19

• Placed on a ventilator for three weeks and has been moved to a rehabilitation center

• Has since tested negative, however, some symptoms persist

• Suffered from a grade 3 torn ankle ligament 2 years prior

Current Information

Current

Information

• Lengthy time on ventilator and inadequate therapy has caused severe complications
• Deteriorating physical health
• Incontinence
• Mood alterations

• Determined to regain his strength
• Lengthy process is causing a loss in faith
• Worries about his professional identity

Social/Support Systems

Social and Support Systems

• Prior to hospitalization, Damien lived with his parents and three siblings
• Eunice and Damien Senior Crest (emergency contact)

• Very social
• Close to his family
• Interacted with friends and teammates daily

• Relies on his nurse, personal support worker, and physiotherapist to care for him

Information

Relevant To Care

• Stage 2 pressure injury on sacrum area

• Experiences severe complications
• Loss of lean muscle mass
• Overall weakness
• Difficulty breathing
• Foot drop on both feet
• Joint contractures in the ankles, knees, and hip

• Unable to independently perform activities
• ADLs, nutrition, hygiene, ambulation, elimination (incontinence)

• Is depressed with his current overall medical condition; experiences mood alterations

Information Relevant To Care

Further

Assessment Data

Further Assessment Data

• Formerly diagnosed with acute respiratory distress syndrome and COVID-19

• Suffers from decreased flexibility

• Tires easily, especially during feeding

• Has vital signs taken regularly:
• Temperature, pulse, respiration (OD)
• O2 Saturation (OD)
• Blood pressure (OD)
• Pain Assessment (q shift/prn)
• Color, sensation, movement (prn)

Impaired mobility r/t

overall weakness, joint contractures, and foot drop

Nursing Diagnosis #1

Priority area of care: Mobility

Transient incontinence

r/t length on ventilator

Nursing Diagnosis #2

Priority area of care: Elimination

Impaired mobility r/t overall weakness, joint contractures, and foot drop

Impaired Mobility

Goal #1

Client will be able to ambulate and move freely without the presence of pain by the end of care

Transient incontinence r/t length of time on ventilator

Transient Incontinence

Goal #2:

Client will be able to eliminate without incontinence by the end of care

Nursing

Safety Factors

Nurse Safety Factors

IP&C

• Appropriate PPE
• Gloves and gown when dealing with bodily fluids
• Client is no longer on isolation precautions
• COVID-19 safety guidelines

Body Mechanics

• Bed at the waist of tallest nurse
• Avoid overstretching/reaching
• Maintain an even balance
• Correct body alignment

Client Safety

Factors

Client Safety Factors

Risk For Falls

• Unsteady gait and overall weakness
• Requires walker
• Call bell placed nearby
• Fall Risk Assessment

General Factors

• Safety rails placed up
• Bed wheels locked
• HoB as low as possible
• Stage 2 pressure injury - Prevent shearing
• Cautious around nut allergy
• Assess the safety of the environment

Infection

Control Practices

Infection Control Practices

• Clean pressure injury with saline water

• Change incontinence brief frequently
• Whenever the brief is soiled or moist

• Antimicrobial dressing
• Covers the pressure injury
• Change daily

Further Assessments

• Pain Assessment
• Assess the effectiveness of Oxycontin
• Patient is said to be in constant pain

• Braden Scale
• Monitor and assess for alterations or worsening pain

• Respirations
• 10-20 breaths per minute is the normal range
• Improvement/deterioration?

• Assess ability to perform ADLs

Communication Strategies

Communication

Therapeutic Communication Approach

• Open-ended questions
• Use of active listening and silences
• Demonstrate compassion and understanding
• Provide opportunities to phone/video call families and friends
• Update on progress/care

Sensory deficits: N/A

Evaluation

Impaired Mobility

r/t Impaired Mobility

• Assess the client:
• Experiences less or no pain during movement
• Physical condition has improved
• Need for assistive devices
• If less or no longer dependent, this may indicate improvement
• Need for assistance
• If less or no assistance, this may indicate improvement

Evaluation

Transient Incontinence

r/t Transient Incontinence

• Assess the client:
• Is able to eliminate with less or no difficulty
• Is less or no longer dependent on incontinence briefs, urinal and commode
• Requires less or no assistance with toileting
• Demonstrates a consistent/daily elimination pattern