Jackson College

Department of Nursing

NRS 220
Transition Bridge

Comprehensive Nursing Care Plan

________________________Chelsea Bell___________________________________
Name

_______________4/8/20__________________
Date

8.25.19 1
This Assignment supports the COURSE Learning Outcome and Behavioral Competency of

Human Flourishing:
Advocate for the culturally diverse clients and families through the provision of evidence-based care for varied client
populations in way that promote self-determination, integrity and ongoing growth
The Student will deliver culturally responsive care to assist adults in ways that promote self-determination, integrity, and
ongoing growth as human beings.

Nursing Judgment:
Using the nursing process and evidence-based practice, prioritizes and provides safe, quality client-centered care for varied
client populations.

The Student will make judgments in practice utilizing the nursing process to provide safe, prioritized, quality care and
health promotion for adult medical surgical clients and families.

Professional Identity:
Demonstrate legal, ethical and practice standards in the care of varied client populations and advancing one’s professional
identity.

The Student will apply professional and caring behavior towards self and other members of the inter-professional team.
The Student will demonstrate accountability to the patient, health team, and profession.

Spirit of Inquiry:
Apply evidence-based practice standards to guide care of varied client populations.
The Student will Use evidence-based practice standards to guide nursing care for the adult medical surgical client

8.25.19 2
 Priority Nursing Diagnosis List

Problem: Imbalanced Nutrition: Less Than Body Requirements

Etiology: r/t insufficient dietary intake

Signs & Symptoms: Current BMI-17, 40# weight loss in 6m, states “having a difficulty
drinking sufficient fluids, metallic taste in mouth, nausea, only “bites of meal”,
drinks 8/16 oz of ensure,

Problem: Risk for injury

Etiology: abnormal blood profile
Signs & Symptoms: RBC- 3.1, Hgb- 9.7, Platelets- 50

Problem: Risk for pressure ulcer

Etiology: Braden Scale < 18
Signs & Symptoms: Uses wheelchair for ambulation, in bed when not in chair, standby
assist for transfers, client diaphoretic, 40# wt. loss in 6m, only takes “bites of meal”, 24oz
of water a day, 8/16oz of ensure, sedating pain med, emaciated appearance, bony
prominences hips, spinal process, sacrum and coccyx.

Problem: Social isolation

Etiology: Desire to be alone
Signs & Symptoms: Denies offer to notify friends of admission, reports not wanting
visitors.

8.25.19 3
P: Risk for pressure ulcer
E: Braden Scale < 18
Priority #1 Nursing Care Plan
Expected Nursing Interventions Rationale Evaluation of
Outcomes Evidence-based? Interventions
Client will Inspect skin daily, especially bony Pressure ulcers result All implemented
prominences and dependent areas for in additional pain and
remain free intervention were
pallor, redness and breakdown in addition treatment for the client
from to assessing pressure ulcer risk client as well as additional successful in prevention
specific interventions should be health care services
pressure of tissue breakdown.
implemented to prevent tissue injury. and costs. A
ulcers for Implement interventions to prevent tissue comprehensive  An alternating
breakdown.: assessment of the
duration of pressure mattress
 Position client properly; use clients risk for pressure
hospital stay. pressure reducing or pressure- ulcers and proactive was obtained and
relieving devices. (e.g., pillows, gel interventions are
used.
or foam cushions, alternating necessary to reduce the
pressure mattress, air-fluidized bed, risk for tissue injury.  Mild soap was
kinetic bed) if indicated A & L p. 691
used for bathing
 Keep client’s skin clean;
thoroughly dry skin after bathing and a non-
and as often as needed, paying
allergenic lotion
special attention to skin folds and
opposing skin surfaces (e.g., was applies bid.
axillae, perineum, beneath breast.)
pat skin dry rather than rub; use a
mild soap for bathing and apply
moisturizing lotion at least once a
8.25.2019 4
 day.
 Encourage a fluid intake of 2500
mL/day unless contraindicated.
 Increase activity as allowed
 Consult nutrition/dietary support to
evaluate client’s nutritional status.
2. Critically ill clients are at increased Support surfaces are Client used cushion for
risk for pressure ulcers, often requiring often needed to reduce
extra support while in
frequent skin risk assessment and pressure risk for the
prevention interventions critically ill. wheel chair. Client used
A&L pg. 692
air mattress for pressure
relief while in bed.
3. Instruct or assist client to shift weight Frequently preposition Client was successful at
at least every 30 min the client often more
shifting weight every 30
frequently then every
two hours. min
A&L pg 692
4. for clients with limited mobility and A validated risk Client has a Braden
activity, use a risk assessment tool to assessment tool such scale of <18. Client is
systematically assess immobility and as the Norton or at high risk for pressure
activity-related risk factors. Braden scale should be ulcers.
used to identify clients
at risk for mobility-
related skin
breakdowns
A&L pg. 807

8.25.2019 5
 TEACHING PLAN

Teaching Topic
Ways to prevent skin breakdown

Client’s Current Understanding of Topic

Client has some understanding of how to prevent skin breakdown. She understands she
should change positions frequently to allow for tissue profusion.

Client’s Learning Style

Visual, audio

Client’s Readiness to Learn

Clients willingness to learn is impaired by current state of health.

Teaching Methods Used

Teachings were spread out as to conserve energy. Teachings were done as they were
implemented.

Content Taught: provide content outline AND attach content from reliable CITED source
(Add pages as needed)

While client was in the shower she was taught to do a self-assessment of skin integrity.
Paying special attention to heels and ankles, knees, hips, spine, tailbone area, elbows,
shoulders and shoulder blades, back of head and ears. She was educated to report any
areas of warmth, breakdown, redness or pain immediately. Daily showers are

8.25.2019 6
 discouraged. When showering use warm, not hot water. Use a mild unscented body wash.
When drying pat instead of rubbing. Client was instructed to apply nonallergenic lotion
daily.
 While in bed client was educated to not place pillows under knees. It puts pressure
on heels. Instructed to never drag self to change position or get in and out of bed,
ask for help if its difficult to move. Change position every 30 minutes. An
alternating pressure mattress was obtained and used. Client was also instructed to
increases her water intake by at least 10oz/day.

Evaluation of Learning
Client was able to successfully implement teachings of how to prevent skin breakdown.
Client has done self-skin assessments (in addition to nursing assessments) noting any
areas of concern. She was able to identify new redness to right hip. Client has increased
her water intake from 24oz to 34oz/day. .

Resources:

Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing diagnosis handbook: an evidence-based

guide to planning care. St. Louis: Elsevier.

8.25.2019 7
8.25.2019 8