CASE SCENARIO:

Mr Nash is a 75 year old widowed. He lives alone and has two children, 5 grandchildren ages 2-12. Who visits regularly. His prescribed medications are baby aspirin, a beta-
blocker, a thiazide diuretic and warfarin. His none prescribe OTC medication are a multivitamin, Vitamin C, Vitamin E, Calcium tablet, and Bayer Pm for sleep. For an upset
stomach he takes Tums, and for headache either aspirin or acetaminophen. He also takes laxatives for constipation which he develops recently. He is considered about feeling wash
out, sleeping poorly and feeling chronic fatigue.
Within the last two weeks, He has not been able to do his usual daily half mile walk. @4 hour diet revealed the following:
Breakfast-grape fruit juice, blueberry muffin, coffee with cream
Lunch-grilled cheese and tea
Late afternoon-glass of milk with cookies
Dinner-cheese with crackers and wine, broiled chicken, peas, carrots, mashed potato. Butter, chocolate ice cream
Bed time snack-coffee flavoured yoghurt

With the Case presented, make a NURSING CARE PLAN following the format below, prioritizing the needs of the client:
Assessment Nursing Diagnosis Background knowledge Planning Intervention Rationale Evaluation
Subjective/Objective
Subjective: Risk for injury Blurred vision refers to a lack of Short Term Goal: After 8 Obtain medical Determine if Short Term Goal: After 8
Patient stated that Herelated to loss of sharpness of vision resulting in the hours of nursing intervention and bowel constipation is an effect hours of nursing intervention
is feeling wash out, visual acuity inability to see fine detail. Blurred the patient will be able to: history of other treatment or is the patient was be able to:
and is sleeping poorly vision may result from   functional. Many  
and feeling chronic Constipation related abnormalities such as Verbalize understanding Assess supplements (iron) and Verbalize understanding
fatigue to Medication use as nearsightedness, farsightedness, of individual factors that abdomen medications may cause of individual factors that
evidenced by dry, presbyopia, or astigmatism that contribute to possibility constipation. contribute to possibility
Objective: hard stool can be improved with corrective of injury Educate patient of injury
Sensory dysfunction lenses (eyeglasses) or it may   on diet and Patient may have  
Less than three bowel Activity intolerance signal the presence of eye disease. Establish or return to normal lifestyle palpable mass on left Establish or return to normal
movements per week related to poor patterns of bowel functioning. modifications side that is indicative of patterns of bowel
habits of sleeping as Constipation is infrequent bowel constipation. functioning.
evidenced by movements or difficult passage of Verbalize increased energy, Ascertain Dietary changes help
fatigue. stools that persists for several proper sleeping routine and knowledge the colon process stool Verbalize increased energy,
Disturbed sleep weeks or longer. Constipation is improved well-being. of safety and help make the stool proper sleeping routine and
pattern related to generally described as having needs/injury easier to pass. improved well-being.
impaired physical fewer than three bowel movements Long Term Goal: After 3 prevention and
mobility secondary a week days of nursing interventions, motivation To prevent injury in Long Term Goal: After 3
to aging and familial the patient will be able to: home, community, and days of nursing
isolation. Fatigue is a condition Assess patient’s work setting interventions, the patient was
characterized by a lessened Demonstrate behaviors, sleep patterns be able to:
capacity for work and reduced lifestyle changes to reduce and changes, Provide information on
efficiency of accomplishment, risk factors and protect self naps, and which to establish a Demonstrate behaviors,
usually accompanied by a feeling from injury frequency, plan of care for lifestyle changes to reduce
of weariness and tiredness. Fatigue   amount of correction of sleep risk factors and protect self
can be acute and come on Recognizes measures that activity, deprivation. from injury
suddenly or chronic and persist. prevent or treat constipation sedentary  
status, number Recent loss, loss over a Recognize measures that
Disturbed Sleep Pattern may Patient will report the ability to and time of long period, long prevent or treat constipation
include insomnia, narcolepsy, perform required activities of awakenings standing loss have
restless leg syndrome, and daily living during night, different implications Patient has reported the
breathing-related disorders and patient’s for nursing intervention ability to perform required
(obstructive sleep apnea). Patient will maintain complaints of and the patient’s level activities of daily living
Excessive daytime sleepiness (or functional mobility as long as fatigue apathy, of adaptation or
sudden somnolence) is a symptom possible within limitations of lethargy, and resource use may be Patient has maintained
that can occur with several sleep disease process impotence difficult to articulate. functional mobility as long
disorders as possible within limitations
Patient will achieve optimal Determine of disease process
Impaired Mobility is a decrease functioning within limits of nature of visual
in muscle function, loss of muscle visual impairment as symptoms,
mass, reduction in muscle evidenced by ability to self- onset and Patient achieved optimal
strength, gait changes affecting care, navigate environment degree of visual functioning within limits of
balance, and stiffer and limited safely, and to engage in loss. visual impairment as
mobile joints can significantly meaningful activities. evidenced by ability to self-
jeopardize the mobility of aged care, navigate environment
patients. Mobility is needed safely, and to engage in
especially if an individual is to meaningful activities.
maintain independent living.