NUR 171

Supportive Educative Nursing

Comprehensive Nursing Care Plan

Alexandria Rose
Name

11/21/15
Date

6.26.2012

6.26.2012

Priority Nursing Diagnosis List

Problem

Risk for impaired skin integrity.

Etiology

General Weakness

Signs & Symptoms

Gradual, worsening immobility and inactivity. According to the son, the patient has been laying

on the couch for the majority of the past 4 days.

Problem

Risk for decreased cardiac output

Etiology

Hypertension

Signs & Symptoms

Persistent systolic BP of >140 or diastolic BP>90 without blood pressure medication (Today,

162/76). This indicates increased peripheral vascular resistance, which causes increased work of the heart. Patient also
complains of occasional palpitations and angina.
Problem

Readiness for enhanced knowledge

Etiology

Client expresses interest in learning

Signs & Symptoms

6.26.2012

Client asks questions regarding the effects of tobacco on HTN

Priority #1 Nursing Care Plan

Nursing
Diagnosis
P: Risk for
impaired skin
integrity

E: General
Weakness

S: Gradual,
worsening
immobility and
inactivity.
According to the
son, the pt has
been laying on
the couch for the
majority of the
past 4 days.

6.26.2012

Expected
Outcomes
Client will verbalize
understanding of
treatment/therapy
regimen (Doenges,
Moorhouse, Murr
pg. 865)

Evaluation of
expected
outcomes

Goal Met
AEB client states
she understands
that in order to
regain her normal
mobility, she needs
to work with PT
during in home
care.

Nursing Interventions

Rationale
Evidence-based?

Evaluation of
Interventions

1. Assess: Perform routine

skin inspections assessing
color, temperature, surface
changes, texture, and
contours.

1. Rationale: Systematic
inspection can identify
developing changes and
promotes early intervention,
thus reducing likelyhood of
progression to skin breakdown
(Doenges, Moorhouse, Murr pg.
866).

1. Goal met.
AEB client identified 2
moles that had changed
in appearance.

2. Intervene: Place the

clients legs in an elevated
position when sitting or
laying.

2. Rationale: To enhance
venous return and reduce
edema formation (Doenges,
Moorhouse, Murr pg. 868).

2. Goal met.
AEB client's legs were
elevated when sitting in
the bedside chair.

3. Teaching: Teach the

patient proper maintenance
of skin hygiene: using mild
nondetergent soap, drying
gently and lubricating with
emollient as indicated.

3. Rationale: To reduce risk of

dermal trauma, improve
circulation, and promote
comfort (Doenges, Moorhouse,
Murr pg. 867).

3. Goal met.
AEB client repeated
back the importance of
thoroughly drying moist
areas, such as under
her breasts.

4. Discharge Planning:
Encourage abstinence from
smoking.

4. Rationale: Smoking causes

vasoconstriction, which
prevents blood, oxygen and
nutrients from flowing to body
tissues, thus delaying healing
(Doenges, Moorhouse, Murr pg.
868).

4. Goal not met.

AEB client states that
she wishes to quit
smoking, but

Priority #2 Nursing Care Plan

Nursing Diagnosis
P: Risk for decreased
cardiac output.

E: Hypertension

S: Persistent systolic BP >140

or diastolic BP >90 without
blood pressure medication
(Today, 162/76). This indicates
increased peripheral vascular
resistance, which causes
increased work of the heart. Pt
also complains of occasional
6.26.2012

Expected
Outcomes

Nursing
Interventions

Client will display

hemodynamic
stability (blood
pressure, cardiac
output, renal
perfusion/urinary
output, peripheral
pulses) (Doenges,
Moorhouse, Murr
pg. 172).
Evaluation of
expected
outcomes

Goal partially
met.
Blood pressure is
WNL after blood
pressure
medication is
administered,
5

Rationale
Evidence-based?

Evaluation of
Interventions

1. Assess: Assess vital

signs/hemodynamic
parameters including
cognitive status. Note
vital sign response to
activity or procedures
and time required to
return to baseline.

1. Rationale: Provides baseline

for comparison to follow trends
and evaluate response to
interventions (Doenges,
Moorhouse, Murr pg. 174).

1. Goal met.
AEB vital sign check and
neurological assessment
were performed and
recorded.

2. Intervene:
Administer blood or
fluid replacement,
antibiotics, diuretics,
inotropic drugs,
antidysrhythmics,
steroids, vasopressors,
and/or dilators, as
indicated. Evaluate
response.
3. Teach: Provide for
diet restrictions (e.g.
low-sodium, bland,
soft, low-calorie/fat
diet with frequent small
feedings) as needed.

2. Rationale: Evaluate response

to determine therapeutic,
adverse, or toxic effects of
therapy (Doenges, Moorhouse,
Murr pg. 175).

2. Goal met.
AEB Losartan (a
vasodilator) was
administered and blood
pressure returned to
acceptable range.

3. Rationale: To maintain
adequate nutrition and fluid
balance (Doenges, Moorhouse,
Murr pg. 177).

3. Goal not met.

AEB physician did not
change diet order, so
client continued current
diet.

palpitations and angina.

peripheral pulses
are +2 regular
rate/rhythmbut
I&O were not
ordered
4. Discharge Planning:
Discuss significant
signs/symptoms that
require prompt
reporting to healthcare
provider (e.g. muscle
cramps, headaches,
dizziness, skin rashes).

6.26.2012

4. Rationale: These may be

signs of drug toxisity and/or
electrolyte loss, especially
potassium (Doenges,
Moorhouse, Murr pg. 177).

4. Goal met.
AEB patient states she
will report any
palpitations, skin rashes,
muscle cramps or
dizziness to her care
provider.

TEACHING PLAN
Teaching Topic
Causes of HTN and specific lifestyle changes to lower blood pressure.
Clients Current Understanding of Topic
Client understands that her blood pressure is high, but is unaware of risk factors or causes.

Clients Learning Style

Client is a visual learner.
Clients Readiness to Learn
Client asked questions regarding what effects tobacco has on the body, indicating
readiness for enhanced learning.
Teaching Methods Used
Verbal explanation and written packet with information to take home.

Content Taught (provide content outline or attach content from reliable source)
The education focused on healthy meal choices and smoking cessation. The client was taught
that low sodium foods have potential to lower blood pressure. The client was also taught that her
smoking habits are likely a main cause of her current HTN.
Evaluation of Learning
The client seemed to understand the teaching, however she still seemed reluctant to make further
efforts to quit smoking.
Resources:
http:www.jblearning.com/samples/0763751375/46436_CH05_000_000.pdf
http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/lifestyle-home-remedies/con20019580?p=1
Ackley and Ladwig: Nursing Diagnosis Handbook. Mosby
Readiness for enhanced knowledge
6.26.2012

Deficient Knowledge
Ineffective Health Maintenance
Ineffective Therapeutic Regimen Management
Fundamentals of Nursing textbook

6.26.2012