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Practical Nursing Humber ITAL Mini Care Plan

Step 1 Analysis
Student Name: Date:
Week:
Client Age
Living
Diet
Activity
Diagnosis Problem
s
Accommodati
Level
Initials
on
CCC
G-feed
immobile Scrotal Debris
C,J
28
Step 1 Assessment All Modes
Adaptive/
Ineffectiv
e
Physiological (all systems)
+/Problem
Ventilation
Diagnosis:
anoxia
History:
Anoxia brain injury
Lifestyle:
immobile
Assessments:
O2Sat: 91
R: 18
Rhythm: strong,
fast
Breathing effort: effortful
Inspection:
Cough: Yes
Sputum: Yes, white frothy.
Symmetrical expansion: Yes,
round
Crackles: present
Wheezes: present
Medications:
Lab Values:
Total CO2: 46
Cardiovascular
Diagnosis:

History:

Lifestyle:
- smoker: N Alcohol: N
Assessments:
P: 115 b/min and irregular
BP: 136/100
O2Sat: 98 on humidifier
Capillary refill: less than 2

-Ineffective airway
clearance
-Ineffective breathing
pattern

+
-

-Risk of getting infection


-At risk for impaired gas
exchange.
-at risk for tissue
perfusion.

+
+
+
+

- at risk for hypertension


- at risk for

seconds
Inspection:
Skin color:
Nail beds:
No pallor
No abnormal pulsations visible
on pericardium No
Auscultation:
S1 & S2 identified Yes
No murmurs
Palpation:
Pulses palpable:
o Dorsalis pedis: present
o Radial : present
Edema: Yes Where? Feet
Gradiant:
Medications:
Lab Values:
Troponin: 7.3
CK: 25
CKMB: 19
PTT: 30
INR: 1.3
Fluid & Electrolytes
Diagnosis:
Lack of fluids
History:
Immobile

+
+
+
+
+
+
-

At risk for open sores,


SOB, redness.

-Fluid volume deficit


-Impaired physical
mobility

Lifestyle:
NG Tube

-Patient is at risk for skin


tearing due to dryness

-Patient is at risk for


dehydration

Assessments:
Amount of Fluid taken orally: None

IV: yes
Flushes: Yes, every 3 days
1300ml per day
G/NG Feeds: Yes

-at risk for dehydration


and little urine output
-at risk for phlebitis,
occlusion, and other
intravenous adverse
effects.

Inspection:
Palpation:
Skin turgor:

-Fluid Volume imbalance


as pt cannot move.

Edema

Lab Values:
Na: 138
Potassium: 4.0
Chloride: 100
Urea: 4.4
Creatinine: 25
Nutrition
Diagnosis:

History:

Lifestyle:
immobile
Assessments:
H: 175
W: 75.4kg
BMI:
Type of Diet: G-tube
Appetite:
Inspection:
Palpation:
Auscultation:
Medications: Multivitamin

Altered nutrition as
pt cannot eat PO
and uses a G-feed

-Patient at risk for


malnutrition

Impaired
swallowing as the
pt is using a trach
tube and gets
nutrition from gtube instead.

Elimination
Diagnosis:
Bowel incontinence
History:
Lifestyle:
Bed written
Assessments:
Catheter: yes
Colostomy: no
Urinary output: >30ml/hr
Amount: 600 ml output
Color: Concentration Odor:
yes Other: sediment in urine
Infection: yes
Bowel Habits: qd, with

+
+
+
+
+
+

- at risk for loss of bowel


function

-at risk for infection

- Patient at risk for bowel


obstruction, constipation and
fluid retention

laxatives
Abdomen: round
BS x 4 quadrents: present
Inspect: Ng tube
Palpate: skin is clammy
Auscultate: bowel sounds
present

Medications:
Docusate sodium
Sodium bicarbonate
Lactulose
sennosides
saccharomyces boulardi

Lab Values:
Creatnine: 25
Urea: 4.4
Sodium: 138

Activity & Rest


Diagnosis:
Bed ridden
History:

Lifestyle:
Bed written

Assessments:
(Musculoskeletal Assessments)
Physiotherapy:
Yes, ROM exercise
Sleep:
Patient sleeps through the
night
Skin Integrity
Diagnosis:
Impaired skin integrity
History:

Lifestyle:
Immobile
Assessments:
Skin integrity: poor

- Lack of movement due to


inability to move slows
bowel movements and can
create complications such
as constipation, leading to a
higher BP.

-at risk for diarrhea and


dehydration

+
+
+

-At risk for skin


deterioration
-At risk for lack of mobile
function and high rigidity.

-Impaired physical
mobility due to lack of
brain function.

-At risk for ulcers, skin


breakdown, and
dehydration

-At risk for wound to turn


into infection and ulcers
-At risk for skin
breakdown and poor
tissue perfusion

Wounds: yes
Dressings: yes
Inspection/Appearance: sweat
Skin Turgor: poor
Medications:
The Senses
Diagnosis:
N/A
Lifestyle:
No deficiencies noted
Assessments:
Vision: no
Hearing: no
Speech: no
Tactile: no
Olfactory: no
Assistive devices: no
Pain: 0
Pain Management:
Medications:
acetaminophen
Neurological Function
Diagnosis:
Limited brain activity due to
anoxia
History:
N/A
Assessments:
Oriented: No
Mental Status: incompetent
Behavior: unable to cooperate
Motor Function: unable to
operate
Strength in arms is none
Medication
-Baclofen
-Phenytoin
Endocrine Function/Reproduction
Diagnosis:

+
-

-Diminishment of nerve
cells due to lack of nerve
cells firing.

-Sensory-perceptual
alterations
-At risk for Impaired
verbal communication
- at risk for little to no
brain activity
- at risk for body to shut
down due to lack of brain
activity.

-at risk for mental


confusion, decreased
coordination
-at risk for skin rash or
itching.

History:

Assessments:
Diabetes: no
BS: WDL
Lab Values:
TSH: 1.4
Creatnine: 25
Gamma GT: 742

Psychological Mode
Self-Concept
Personal self:
Coping mechanism:
Facial expression:
Gender: male
Age: 28
Interests to self:
Role Function
-son
- mother involved in care
Interdependence
Staff nurses
2 person assist

+/-

Problem
-at risk for ineffective
individual coping
- at risk for
powerlessness