Nursing

Careplan

NURSING EXPECTED PATIENT ASSESSMENT ACTION TEACHING
DIAGNOSES OUTCOMES interventions: interventions: interventions:


At risk for Patient will maintain Assess for Patient is not The patient’s
decreased blood pressure in fatigue, typically active spouse
cardiac output the range of 120- dyspnea, edema, on a daily basis; mentioned that
r/t hypertension 130/60-70 for the orthopnea, patient is only their daughters
and next two weeks. weight gain, walked by visit weekly.
hyperlipidemia oliguria, clammy student nurses. Since the family
skin, skin color As evidenced is active in the

changes, chest the day involves patient’s life,
pain eating meals and they should be
laying in the taught about
recliner and restrictions and
watching TV regulations that
with her should be
husband. Due to implemented to
being a fall risk, decrease risk of
the patient will her blood
need exercises pressure rising.
that she would The family will be
be able to do taught when
that do not taking the
cause an patient to
increased risk of restaurants or
falling. The when bringing
patient can walk food to the LTC
with assistance, facility to limit
but other the amount of
exercises should sodium and fat
be done in that is present in
addition to the food that the
ambulation, to patient

not fatigue consumes on

patient. One their watch. The
exercise to be patient should
performed will not exceed 1300
be rolling a ball mg of sodium per
back and forth day. The patient
to the student should not
nurse. The exceed 35-60
patient will sit grams of fat per
on one end of day.
the table in the

activity room
and the student The family will
nurse on the also be taught to
other side. They use the gait belt
will roll a ball and assist in
back and forth ambulation of
to each other for the patient with
20 minutes per the FWW.
shift. In order for
Exercise is an
the patient to important part in
comply, the maintaining
patient will be blood pressure,
awarded 30 so the more the
minutes of patient is able to
television time walk, the less
in her room likely the patient
after the 20 is of having
minute exercise. increased blood
pressure. The

beginning goal
It was noticed for the family
that the patient would be to walk
would fidget to patient from
with her blanket her bedroom to
while watching the common area
TV. An object and back once
such as a Rubiks per visit.
cube should be
2



used by the
patient during
the times she is
watching TV.
The Rubiks cube
should be placed
on the table
with the remote
so she will see it
when turning on
the TV. Instead
of playing with
her blanket, she
could twist the
Rubiks cubes in
different
directions. The
exercise is more
about keeping
her mind active
and involving
movement that
otherwise she
would not
engage in. The
goal is not to
match the
colors. Any sort
of movement or
exercise would
be beneficial in
trying to
maintain blood
pressure. The
colors within the
Rubiks cube may
entice her to
stay interested.

Impaired verbal The patient will Assess for Patient will be The patient’s
communication speak three full anxiety, change taken to activity spouse was able
r/t lack of sentences to in ability to room and be to effectively
communication another individual receive, process, given a communicate
AEB difficulty by the end of the transmit magazine/book with SN but did
forming shift. information, of her choice. not try to
sentences, hearing deficit Patient will be communicate
inability to encouraged to with the patient
complete a full read the bolded due to her
sentence, headings to the impaired verbal
mumbling, word SN, volunteer, communication
salad, difficulty spouse, etc skills. Encourage
comprehending aloud. (Side the husband to
communication, note: this was try to engage in
inability to have implemented in daily
conversation clinical on conversation
with husband Wednesday and with the patient
it was and allow

successful. The sufficient time
patient was able for the patient to
to use adjectives respond.

to describe
I would
pictures and
encourage the
able to read
family to seek
some words
out opportunities
from the
for the patient to
headings)
attend sessions
Patient used to with a speech-
hold position of language
being pianist for pathologist. I
the church her would also
husband was encourage the
pastor of. Since patient and her
the patient is family to discuss
passionate this with her
about playing physician at the
music an next visit. Nurses
intervention are able to assist

would be to sit in many aspects

with the patient of care, but it is
at the piano in also important to
the common recognize when
room and ask the issue is out of
her to show me our realm of
how to play. I practice and we
would ask need to
patient open collaborate with
ended questions other healthcare
about the piano professionals.
and how to play
to engage her in
conversation.
Since the patient
is
knowledgeable
about this
subject, I am
hoping that she
would be able to
present her
thoughts more
clearly.
Stress overload Patient will reduce Assess for the Encourage Instruct patient
r/t stressors and stress levels by resident’s patient to walk to do imagery
tension AEB completing visual current level of to porch and sit meditation every
retelling 4-5 imagery meditation anxiety, stress, in the sun with day for 15
times the for 15 minutes every and signs and her close friend minutes, but also
traumatic day for the next symptoms of or to go to whenever the
depression.
experience of three weeks. exercise groups thought of past
Assess for
witnessing a cat in order to traumatic
patient’s
eating a bird preferences with increase physical experiences
outside her activities that activity. Physical enter her mind.
window and are offered on activity is a The patient has a
how it makes health care floor beneficial way to CD player in her
her feel unsafe and on campus. decrease stress. room with a CD
in her room and Ask patient If patient refuses of relaxing music

how she does about sleeping to leave room, so I will teach her
not sleep well patterns and do chair to play her music
because of it, as habits; compare exercises that in the
well as the with change of she can do in her background
continuous shift information wheelchair or on while she
effects that her to include pain side of bed. meditates.
and insomnia
brother’s death These can
notes for 11-7 My patient
during the war include arm
shift enjoys coloring in
where he circles, leg lifts,
her coloring
drowned has on ROM exercises,
books, so
her etc.
introducing other
ways that she
could be creative
The patient
will be beneficial
often mentioned
to take her mind
religion and
off of what she
prayer and the
has witnessed
role they have in
and focus her on
her daily life.
developing new
Initiating a
creativity skills. I
prayer group
will introduce
where those
new hobbies
within the long-
such as crafts,
term care facility
painting,
meet once
drawing, creative
weekly and
writing,
compose and
photography,
share a prayer
reading, puzzles,
list of concerns
and/or knitting
that they all
and teach her
have would be
close friend in
beneficial for my
the LTC facility
patient to be
the same skills,
apart of. This
so they can do
serves as a
them together
support group,
while they
as well as giving
socialize. This will
my patient a
also serve as a
sense of purpose
6



because she is support system

being relied on for the patient.
to pray for
others and be
supportive to
them. She has a
very close friend
in the facility, so
trying to
convince the
friend to join as
well would give
the two of them
something to do
together.